A client who had surgery 3 days ago is sitting with the head of the bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?
Lower the bed prior to helping the client to move up in bed.
Encourage the client to eat all of the meals that are sent.
Offer fruit juice at least twice during both the day and evening shifts.
Have the client hold a pillow over the abdomen to cough and deep breathe.
The Correct Answer is A
Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.
Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.
Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.
Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: To avoid pain-causing activity is not the best outcome statement for the nurse to include in this client's plan of care. It does not address the problem of activity intolerance, but rather reinforces the client's refusal to ambulate. It may also delay the client's recovery and increase the risk of complications.
Choice B reason: To take analgesics as prescribed is a relevant outcome statement for the nurse to include in this client's plan of care, but not the best one. It may help to reduce the client's pain and improve his comfort, but it does not directly measure the client's activity tolerance or mobility.
Choice C reason: To show evidence of incision healing is an important outcome statement for the nurse to include in this client's plan of care, but not the best one. It indicates the client's progress and recovery from surgery, but it does not reflect the client's activity intolerance or pain level.
Choice D reason: To ambulate without discomfort is the best outcome statement for the nurse to include in this client's plan of care. It addresses the problem of activity intolerance related to pain, and the goal of increasing the client's mobility and function. It also implies that the client's pain is well-managed and his incision is healing.
Correct Answer is A
Explanation
Choice A reason: Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.
Choice B reason: Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.
Choice C reason: Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.
Choice D reason: Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.
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