An older adult client recovering from coronary artery bypass surgery becomes weak and dizzy when standing to ambulate in the hall with the unlicensed assistive personnel (UAP). The UAP assists the client back into bed and notifies the nurse of the occurrence. Which intervention is most important for the nurse to include in the client's plan of care?
Provide client with dietary teaching regarding a cardiac diet.
Obtain client's vital signs every 4 hours when awake.
Obtain a blood pressure reading before client gets out of bed.
Measure and record the client's urinary output every day.
The Correct Answer is C
Rationale:
A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.
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Correct Answer is C
Explanation
Rationale:
A. A white blood cell count of 8,000/mm³ is within the normal range and does not indicate a need for dosage adjustment.
B. Inelastic skin turgor may indicate dehydration or aging but does not directly affect drug dosage.
C. Elevated serum creatinine levels indicate impaired renal function, which necessitates a reduced dosage of medications excreted through the kidneys, such as ticarcillin disodium.
D. Thin, fragile veins are a concern for intravenous access but do not affect the medication dosage.
Correct Answer is A
Explanation
Rationale:
A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.