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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. White blood cell count of 8,000/mm3 (8 X 109/L). B. Inelastic skin turgor. C. Serum creatinine of 3.5 mg/dL (310 μmol/L). D. Thin, fragile hand and arm veins. E. Serum creatinine of 3.5 mg/dL (310 μmol/L).

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.

A. Administer a prescribed antianxiolytic. B. Allow the client to rest before taking the vital signs. C. Notify the client representative. D. Offer the client hot tea to promote relaxation.

Correct Answer is B

Explanation

Rationale:

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.

B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.

C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.

D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Correct Answer is B

Explanation

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