A client has an injury to the left ankle requiring partial weight bearing. The client is elderly with a history of balance deficit. Which assistive device would be most appropriate for this client?
Age dose of pain medication
Correct method of administering your own pain medication
Operator can push the PCA button for you if you are asleep
The pain medication is delivered at your nose
The Correct Answer is A
Choice A Reason:
Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.
Choice B Reason:
Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.
Choice C Reason:
Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.
Choice D Reason:
The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Correct Answer is B
Explanation
Choice A Reason:
Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.
Choice B Reason:
Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.
Choice C Reason:
Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.
Choice D Reason:
Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.
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