Basic Care & Comfort/Pain Mangement
A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond?
"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3).
A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "I can see that you are very upset. Let's talk about what happened." 2. "I'll report the technician to the head of the radiology department." 3. "The technician never should have said that to you." 4. "Your health care provider will discuss treatment options with you."
Correct answer 1 Explanation: Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations.
A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal Cannula 2.Non-rebreathing mask 3. Oxymizer 4. Venturi Mask
Correct answer: 4 Explanation: The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD.
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action?
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The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care
Correct answer 1,2,3,5 Explanation: Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option 3) - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible (Option 1). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option 2). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option 5). (Option 4) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care.
The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue teaching the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the teaching by following the client's movements 4. Provide written instructions and a private place for the client to learn independently
Correct answer: 1 Explanation: Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.
A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take? 1. Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client 2. Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided 3. Explain the client's condition, but inform the spouse that entering the room is not allowed until the client is stabilized 4. Inform the spouse that being in the room during procedureds is unsafe for the client, and escort the spouse to the waiting area
Correct answer: 1 Explanation: Family member presence at bedside during invasive procedures or resuscitation efforts is an important component of psychosocial care for the client and family. When a client's support person is allowed to be present at bedside to witness care during acute events, the support person is often able to better understand the client's condition and may have decreased anxiety and better coping with unexpected or poor outcomes (eg, cardiac arrest, death). Therefore, the nurse should, when possible, support and facilitate family presence in the room and provide information about the events that are occurring (Option 1).
The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1. Client's respiratory status 60 min later 2. documenting client's hypoxic events. 3. Obtaining an order for different analgesic. 4. Potential for drug-drug interaction now.
Correct answer: 1 Explanation: Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary.
A client who is 24-hours postoperative bowel resection is receiving IV opioids for severe pain. The nurse reviews the health care provider's (HCP's) prescription to discontinue the continuous IV fluids and advance the diet from clear liquids to regular diet as tolerated. What is the nurse's most appropriate action? 1. Apply a saline lock adaptor 2. Contact the HCP to request a prescription for a saline lock 3. Remove the IV catheter 4. Slow the IV fluids to a keep-vein-open rate
Correct answer: 1 Explanation: The nurse identifies severe pain as a major problem because if it is not controlled adequately, the client is less likely to move or breathe deeply and more likely to develop postoperative complications (eg, venous thrombosis, atelectasis, pneumonia). The nurse should discontinue the IV infusion and apply a saline lock adaptor to maintain IV access (without clotting). The HCP's prescription to lock the IV catheter is implied, as the client is currently receiving IV opioids.
The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client? 1. "Ask the client's wife if she would like to give the bed bath." 2. "Do not make eye contact with the client during the bath" 3. The client may prefer for you to talk to him during the bath" 4. "Touching the head is a sign of disrespect; let the client wash his own face."
Correct answer: 1 Explanation: To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear 2. The client has a 30-degree bend at the elbow when walking 3. The crutches and injured foot are moved simultaneously in a 3-point gait 4. There is a 3 finger-width space noted between the axilla and axillary pad
Correct answer: 1 The proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating.
The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1. Cervical cancer 2. Hypertension 3. Ischemic Stoke 4. Osteoporosis 5. Skin Melanoma
Correct answer: 1,2,3 Explanation: The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3).
A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? Select all that apply. 1. Administer docusate orally, daily 2. Administer ondansetron IV PRN for nausea 3. Apply an abdominal binder 4. Implement caloric restriction to promote weight loss 5. Monitor blood sugar to maintain tight glucose control
Correct answer: 1,2,3,5 Dehiscence is a complication of poor wound healing that occurs when the edges of a surgical wound fail to approximate and separate (ie, partial or total separation of the skin and/or tissue layers). Dehiscence is associated with factors that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use) and with mechanical stress on the wound (eg, straining to cough, vomit, or defecate). Interventions to prevent abdominal wound dehiscence include: Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid pain medications (Option 1) Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting (Option 2) Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving (Option 3) Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose; <180 mg/dL [10 mmol/L] random glucose) to decrease infection risk and promote wound healing (Option 5) Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving (Option 4) Wound healing requires adequate caloric and protein intake. Although this client is obese and needs education to promote weight loss, caloric restriction could delay wound healing.
A post-surgical client is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client is arousable and responds to verbal commands. One hour later, the client is again difficult to arouse, with minimal response to physical stimuli. Which actions should the nurse take? Select all that apply. 1. Administer oxygen 2. Assess respiratory rate 3. Initiate rapid response or code team 4. Notify the health care provider 5. Prepare a second dose of naloxone
Correct answer: 1,2,4,5 Explanation: A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1-2 hours. The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription).
The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate order in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply. 1. Allow family member to assist with care 2. Call the medical examiner for an autopsy 3. Gently close the client's eyes 4. Place a pad under the perinium 5. Remove the client's dentures.
Correct answer: 1,3,4 Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible (Option 1). To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes (Option 3). Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in (Option 5). A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 4). Place a pillow under the head to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client's belongings to a family member or send with the body.
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1.Epoetin alfa 2. Fresh froen plasma 3. Homologous packed red blood cells 4. Normal saline 5. Platelet transfusion
Correct answer: 1,4 Explanation: Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1).
An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply. 1. The UAP adds milk to mashed potatoes to make them thinner 2. The UAP encourages the client to occasionally turn the head to the left 3. The UAP helps the client sit in an upright position 4. The UAP places food on the strong side of the client's mouth 5. The UAP puts a straw in a fruit smoothie to prevent spilling
Correct answer: 1,5 Explanation: Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques include the following: Modification of food consistency (pureed, mechanically altered, soft) Thickened liquids Having the client sit upright at a 90-degree angle (Option 3) Placing food on the stronger side of the mouth to aid in bolus formation (Option 4) Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis Some clients who have suffered a cerebrovascular accident (CVA) are also left with visual impairment such as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client with a right-sided CVA may have left-sided hemianopsia. Having the client turn the head during a meal will help the client see everything on the plate (Option 2). (Option 1) Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration. (Option 5) Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.
The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? 1. "Do you have any questions about the diagnosis?" 2. "There are medications available to treat Alzheimer disease." 3. "This new diagnosis must be frightening for you." 4. "We can help you make decisions about your care."
Correct answer: 3 Explanation: Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts.
A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? 1. Administer an inhaled bronchodilator 2. Check marked insertion depth of the tube. 3. Request a prescription for a diuretic 4. Start the client on incentive spirometry
Correct answer: 2 A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately.
A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action? 1. Assess the client's orthostatic blood pressure 2. Assist the client to a sitting position 3. Hold and walk with the client 4. Keep the client on bed rest
Correct answer: 2 Explanation: Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider.
A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? 1. Teach the client how to assess blood pressure daily 2. Teach the client how to prevent constipation 3. Teach the client how to prevent itching 4. Teach the client how to prevent nausea
Correct answer: 2 Explanation: Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener).
Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1. 25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm^3 (18.0 x 10^9/L) 2. 50-year-old client with AIDS who is receiving nonrepinephrine infusion and has a weight loss of 20lb (9.1 kg) in a month, prealbumin level <10mg/dL (100mg/L), and mean arterial pressure of 50 mm Hg 3. 80-year-old client 2 days post hip replacement with dementia, 2 Jasckon-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) 4.87-year-old client 2 days post open cholecystectomy
Correct answer: 2 Explanation: Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells.
A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? 1. "How is your spouse's new job going?" 2. "I notice that you seem frustrated." 3. "It can take time to adjust to dialysis. We have a support group that can be helpful." 4. "It's normal to be angry when you can't work any longer."
Correct answer: 2 Explanation: The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income, or "breadwinner," to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment.
When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain? 1. Client"s ethnic background 2. Client's report of symptoms 3. Client's vital signs 4. Extent of client's injury
Correct answer: 2 The client's self-report of symptoms is always the most reliable indicator of the client's pain. The nurse does not have the ability to determine the extent of pain the client is experiencing—only the client can report this. In the nonverbal client, the nurse may use nonverbal pain scales such as the Wong-Baker pain rating scale.
A teenage client with sickle cell disease is admitted with a diagnosis of crisis. The client's current prescription is morphine 2 mg intravenous push every 4 hours prn. The client appears comfortable while watching television and tells the nurse "I have severe intolerable pain," and rates it a "10." What action should the nurse take? 1. Call the client's health care provider (HCP) to obtain a ibuprofen prescription for pain relief 2. Call the HCP for patient-control analgesia (PCA) at a higher dose of the same drug 3. Contact the HCP who issued the prescription to switch to meperidine 4. Realize the client is exhibiting signs of addictive behavior and needs an appropriate consult
Correct answer: 2 Explanation: Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they may also metabolize the drugs differently. Using only external cues to judge a client's pain is invalid as these clients have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for relief rather than prn administration.
The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. 1. Avoid infusion devices in confused clients as alarms can be disruptive. 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration. 4. Skin protectants and nonprous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45 degree angle on insertion because older adult veins that roll.
Correct answer: 2,3,4 Explanation: The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following: The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1). Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5).
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPAA 5. Teach about one intervention at a time and in the order it will occur
Correct answer: 2,3,5 Explanation: Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5).
A nur se is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say "goodbye" when leaving the room to help orient the client 4. Speak slowly and slightly louder so the client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct answer: 2,3,5 Explanation: The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option 2). Announce room entry and exit to orient and avoid startling the client (Option 3). Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option 5). Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety.
The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply. 1. Ask open-ended questions 2. Face the client while speaking 3. Speak in a loud voice 4. Turn off teh television and close the door 5/Use simple statements and questions
Correct answer: 2,4,5 Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions (Option 5). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option 2). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option 4).
A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting
Correct answer: 2,4,5 Explanation: Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5).
The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading? 1.Dehydration 2. Elevated temperature 3. Hypotension 4. Tachypnea
Correct answer: 3 A pulse oximeter is a noninvasive device that estimates the arterial blood saturation (SaO2) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains both light-emitting and light-sensing components and measures the amount of light absorbed by hemoglobin in the arterial blood. Because the sensor estimates the value at a peripheral site, the oximeter reports the value as SpO2. The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning.
A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises
Correct answer: 3 Explanation: Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing.
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the registered nurse. Which statement would be the most appropriate response? 1. I'll talk w the client to see why the client is angry" 2. It sounds like you shouldn't work w the client so I will reassign you" 3. "Let's go together to talk about the client's concerns" 4. "Why don't you go talk with the client about why the client is angry"
Correct answer: 3 Explanation: Anger is often a sign of psychological distress stemming from anxiety, fear, or loss of control. This elderly veteran has likely had life-long control. Now, with worsening health issues and an acute illness, the client has lost control, causing anger. The feelings are probably accentuated by hospitalization and by staff such as the UAP trying to do things for the client that the client could do alone. A client who is angry should be given the opportunity to express concerns openly. It is important to approach the conversation with an open, accepting, nonjudgmental attitude. The nurse can show the UAP how to deal with these issues. The UAP plays an important role in developing an interdisciplinary plan of care for hygiene and activities of daily living (ADLs) that the client will accept. Therefore, the nurse and the UAP should go together to learn about the client's concerns. They can then work with the client to create a plan for hygiene and ADLs that will allow the client more control while ensuring safety and quality care (Option 3).
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your health care provider (HCP)?" 2. "If I were you, I would be more worried about whether the melanoma has spread." 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." 4. "There is special make-up you can use to hide any facial scars left from the surgery."
Correct answer: 3 Explanation: Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety.
A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? 1. "Don't worry. You'll feel better in a few weeks." 2. "How well are you sleeping at night?" 3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." 4. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant."
Correct answer: 3 Explanation: Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3).
The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin.
Correct answer: 3 Explanation: Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided.
The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? 1. Ask the client when a spiritual leader or clergy memver is coming to visit 2. Document the response and notify the health care provider and perioperative team 3. Follow up the client regarding the nature of the spiritual needs or religious practives 4. Notify the hospital chaplain and tell the client that the chaplain will come by to assist.
Correct answer: 3 Explanation: Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option 3).
A client recovering from femoral-popliteal bypass surgery performed yesterday reports a pain level of 5 on a 0-10 scale. At 2400, the night shift nurse reviews the client's medication administration record, shown in the exhibit. Which medication should the nurse administer? Click on the exhibit button for additional information. 1. Acetaminophen 2. Alprazolam 3. Hydrocodone/acetaminophen 4. Morphine
Correct answer: 3 Explanation: The client is reporting a moderate level of pain. The medication administration record indicates that the client last received hydrocodone/acetaminophen 5 hours ago. It is reasonable for the nurse to choose the oral pain medication for moderate-level pain as the client last received it and then did not require IV pain medication after that administration.
The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? 1. Blisters with a garlic scent near the wrists. 2. Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arms 4. Well-like linear lesions on the back.
Correct answer: 3 Explanation: The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks, cigarette burns, bruises in various stages of healing) should be reported to the appropriate authorities.
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1
Correct answer: 3 Explanation: The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions.
A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3 (0.45 ×109/L). What information contained in the admission history of this client will need to be addressed during discharge education? 1. Eats steamed vegetables daily 2. Enjoy eating grilled shimp weekly 3. Gardens as hobby 4. Takes a bath daily and applies moisturizer
Correct answer: 3 Explanation: This client has a very low absolute neutrophil count (normal: 2200-7700 cells/mm3 [2.2-7.7 ×109/L]); having <500 cells/mm3 (0.5 ×109/L) indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask.
The charge nurse is instructing a new graduate nurse on performing postmortem care. Which client situations might cause the nurse to delay or not perform postmortem care? Select all that apply. 1. Client died following a prolonged illmess 2. Clients's family was not present when death occured 3. Client's religious background requires special ceremonial treatment of the body 4. Death occurred in the emergency department following a suicide attempt 5. Family requests a priest to perform last rites
Correct answer: 3,4,5 Explanation: Postmortem care typically is performed immediately following the pronouncement of death to allow visitation of the deceased by the family. There are several circumstances in which postmortem care may be delayed or not performed. Certain cultural or religious beliefs require that care be performed by the family or clergy (Option 3). The family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way (Option 5). Postmortem care can also be delayed, altered, or not performed in accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity (Option 4).
The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences
Correct answer: 3,4,5 Explanation: Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option 5) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option 4).
A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image? 1. "Do you feel you are able to engage in sexual activity with you prosthesis?" 2. "Do You wear the prosthesis all the time or only when out of the home?" 3. "How do you cope with feelings of self-consciousness?" 4. "Since receiving your prosthesis , how do you see yourself differently?"
Correct answer: 4 Explanation: A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client's undergarments to simulate previous symmetry after a mastectomy or breast trauma. This is an option for clients who are not interested in, or are not candidates for, breast reconstruction surgery. This appliance assists in the promotion of well-being, body image, and sexuality. When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication (Option 4).
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? 1. "Are you concerned about how the surgery will affect your sexuality?" 2. "If you are concerned about infertility, you could always bank your sperm." 3. "The cancer is at an early stage. You are going to be fine." 4. "What have you and your future spouse discussed about your condition?"
Correct answer: 4 Explanation: A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship.
The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? 1. Direct the UAP to apply a protective foam dressing. 2. Document results of the Braden Scale in the electronic record. 3. Notify the health care provider (HCP) 4. Perform an assessment on the client's skin
Correct answer: 4 Explanation: A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would be appropriate to use as part of the assessment.
A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse? 1. "Do you have family or friends who could take care of you?" 2. "I'll make a referral to the local home care agency in your area." 3. "It will be very difficult to manage your care at home." 4. "Tell me how you think your life would be different if you moved from here."
Correct answer: 4 Explanation: After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence.
A client with multiple co-morbidities, including chronic obstructive pulmonary disease, diabetes, and chronic kidney disease, has just been told by the health care provider of the need to start dialysis. The client is in tears and says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now this." Which is the best response by the nurse? 1. "But you need the dialysis to stay alive." 2. "I hope that a kidney donor will be found for you very soon." 3. "It won't be so bad; you might even feel better with dialysis." 4. "Tell me more about what has been overwhelming for you."
Correct answer: 4 Explanation: It is not unusual for clients to feel overwhelmed when managing one or more chronic illnesses. Day-to-day self management includes engaging in activities that maintain and promote physical health, adhering to prescribed medications and treatments, keeping multiple health care appointments, making decisions about health care, and coping with the impact of the illness on physical and social functioning. In this situation, the client felt overwhelmed even before receiving the news about the deteriorating kidney disease requiring dialysis. To help the client plan strategies for self-care and coping with health conditions, it is important for the nurse to identify past barriers to self care and assess aspects of the client's health that were most difficult to manage. Exploring a topic or idea with such words as "Tell me more about..." or "Let's discuss..." is a communication technique that will promote a therapeutic interaction with the client.
During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min
Correct answer: 4 Explanation: Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases.
An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death
Correct answer: 4 Explanation: This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death (Option 4).
A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so the client can ambulate safely with a cane 3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow
Correct answer: 4 On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client.