The nurse is caring for a client who will be discharged on a new blood pressure medication which increases the risk of orthostatic hypotension. Which should the nurse include in the discharge teaching to decrease the risk of injury at home?
A) Encourage appropriate lighting.
B) Provide a bedside commode.
C) Rise slowly when getting up.
D) Monitor activity tolerance.
Answer: C
Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse instructs the client to rise slowly and stand in place for a few seconds until balance is assured. Providing a bedside commode would be appropriate for the client with urinary urgency. Clients with respiratory difficulties or heart ailments would want to monitor their activity tolerance levels. Appropriate lighting would help the client experiencing impaired vision.
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As the nurse working in the clinic, should you run a pregnancy test?
K.W. is an 18-year-old woman who comes to Planned Parenthood for a pregnancy test because a condom broke during intercourse the night before. Her last menstrual period (LMP) was 13 days ago and was normal. She always has a monthly menstrual cycle. She is extremely nervous about pregnancy because she is beginning college on a scholarship soon. She states there have been no other acts of unprotected intercourse since her LMP and declines a gynecologic examination.
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1. Instruct the client that the insulin should be stored away from direct sunlight or excessive heat. 2. Have the client discard the vials. 3. Instruct the client to label each vial with the date when opened. 4. Tell the client this is too much insulin to have on hand.
The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which of the following actions by the nurse indicates a need for further education?
a. The nurse clears the tube with air prior to discontinuing. b. The nurse stops the tube feeding. c. The nurse instructs the patient to cough while pulling out the tube. d. The nurse clamps the tube while pulling it out.