A nurse is assessing a client who is 1 day postoperative following a total knee arthroplasty. The client is scheduled for physical therapy in 45 min. Which of the following questions should the nurse ask first?
“Have you used an incentive spirometer today?"
"What is your current pain level on a scale of 0 to 10?"
"Have you informed your family of your physical therapy schedule?"
"Would you like to bathe before or after physical therapy?"
The Correct Answer is B
A. While the use of an incentive spirometer is crucial for preventing respiratory complications such as atelectasis, this question is less urgent in the context of preparing for physical therapy. The immediate priority should be to assess the client’s readiness for physical therapy, including their pain level and comfort, rather than focusing on the spirometer use.
B. Assessing the client's current pain level is crucial because pain management directly impacts the
client’s ability to participate in physical therapy effectively. Ensuring that the client’s pain is adequately controlled will help in achieving a more successful therapy session and in preventing discomfort or additional complications during the therapy.
C. While informing family members about the physical therapy schedule might be important for planning family support and involvement, it is not as urgent as ensuring the client is physically ready for the therapy session.
D. This question addresses personal preference regarding bathing but is not as critical as assessing the client’s pain level or immediate readiness for physical therapy. While personal hygiene is important, it should not take precedence over addressing pain management and ensuring the client is prepared for physical therapy.
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Related Questions
Correct Answer is C
Explanation
A. A living will does not require approval from a physician; it is a legal document that outlines a person’s
wishes regarding medical treatment in case they become unable to communicate those wishes.
B. Advance directives should be completed while the individual is still capable of making informed decisions, ideally before a serious health issue arises. These documents are intended to provide
guidance on the person’s wishes regarding medical treatment and end-of-life care in situations where they might not be able to communicate their preferences.
C. The durable power of attorney for health care (also known as a health care proxy) is a component of advance directives. It designates a person to make medical decisions on behalf of the individual if they are unable to do so themselves. This document, along with a living will, is part of advance directives that help ensure a person’s health care wishes are honored.
D. A living will does not require a family member’s co-signature to be valid. It must be signed by the individual and may require witnessing or notarization depending on state laws, but not a family member’s co-signature.
Correct Answer is D
Explanation
A. This is primarily the provider's responsibility. The nurse can support the provider by providing information about the procedure and alternative options if requested.
B. While the nurse can provide general information about the procedure, the provider is typically responsible for discussing the specific risks and benefits with the client.
C. This is the responsibility of the medical records department or the provider's office staff. The nurse may be involved in ensuring that the original signed consent is obtained and properly documented.
D. The nurse's role is to verify that the client fully understands the procedure and has given informed consent. This involves assessing the client's comprehension of the information provided by the provider. If the client has any questions or concerns after the provider's explanation, the nurse can clarify them to ensure complete understanding.
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