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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.

Answer and Explanation

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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A. Advise the client to see his healthcare provider for immediate evaluation. B. Encourage the client to keep checking the mole with a magnifying mirror. C. Ask the client if he often spends time outside in the sun without a shirt. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

Rationale:

A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.

B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.

C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.

D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.

A. Clamp the catheter for 30 minutes prior to irrigating. B. Slowly irrigate catheter with saline using an infusion pump. C. Use a sterile syringe to irrigate with 20 mL normal saline. D. Power flush with 60 mL to remove mucous obstructions.

Correct Answer is C

Explanation

Rationale:

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.

B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.

C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.

D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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