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. While additional sleep may be helpful, it does not address the root cause of the hangover effect from temazepam.
B. A benzodiazepine antagonist is typically used in cases of overdose, not for managing next-day drowsiness.
C. Temazepam is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The nurse should advise the client to taper off the medication gradually under medical supervision to prevent withdrawal symptoms and minimize the "hangover" effect.
D. Stopping the medication abruptly can lead to withdrawal symptoms and is not recommended.
Correct Answer is D
Explanation
Rationale:
A. Withdrawing and reinserting the NGT should only be done if the tube is misplaced or dislodged.
B. Sending the fluid to the lab is unnecessary unless there is a specific concern, such as infection.
C. Connecting the NGT to wall suction should only be done after confirming proper placement.
D. Determining the pH value of the aspirated fluid helps verify that the NGT is correctly positioned in the stomach. Gastric fluid typically has a pH of 1 to 5, confirming proper placement.