A nurse is caring for a 24-year-old female client who fell while horseback riding in the accident emergency unit.

Exhibits

A nurse is preparing the client for surgery. Based on the provided data, which of the following are the most critical to address before proceeding with the exploratory laparotomy? Select all that apply.

Choice A rationale: Emptying the bladder before physical activity increases client comfort and prevents urgency or incontinence during ambulation. This also reduces the risk of falls associated with rushing to a bathroom.

Choice B rationale: Patient education and clinical instruction regarding medical conditions are professional nursing responsibilities. The UAP's scope is limited to assisting with tasks and reporting observations, not providing formal teaching.

Choice C rationale: Baseline vital signs are necessary to assess the client's physiological readiness for activity. The UAP can be delegated to collect this data so the nurse can determine if ambulation is safe.

Choice D rationale: UAPs must be instructed on specific subjective or objective signs to monitor and report immediately. Dizziness and light-headedness are critical indicators of activity intolerance or potential syncopal episodes.

Choice E rationale: Assessing the need for assistive devices or safety equipment like a gait belt requires clinical judgment. The nurse must perform this assessment rather than delegating the decision to the UAP.

Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.

Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.

Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.

Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.

Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.

Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.

Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.

Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.