A nurse is caring for a client who is 3 days postoperative following surgical repair of a hip fracture. Which of the following actions should the nurse take to involve the client in decision making?
Report the healing status of the client's surgical site to the provider.
Assist the client to perform exercises and ambulate on the unit.
Consult the client about options proposed by the physical therapist.
Ask the client to their pain on a scale from 0 to 10 every 12 hr.
The Correct Answer is C
A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.
B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.
C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.
D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","F","G","H"]
Explanation
B. Stool results: A positive hemoccult test indicates gastrointestinal bleeding, likely due to a peptic ulcer. Immediate follow-up is needed to assess for ongoing blood loss and the potential for hemorrhagic complications.
C. Heart rate: The tachycardia (118/min) suggests a compensatory response to hypovolemia from gastrointestinal bleeding. This requires prompt intervention to prevent hemodynamic instability.
F. Blood pressure: Hypotension (90/50 mm Hg) is concerning for volume depletion due to chronic or active gastrointestinal bleeding. This requires immediate follow-up to prevent shock.
G. Hemoglobin and hematocrit: A hemoglobin of 9.1 g/dL and hematocrit of 27% indicate anemia, likely due to gastrointestinal blood loss. Further evaluation and potential blood transfusion may be required.
H. Current medications: Ibuprofen use is a major risk factor for peptic ulcer disease and gastrointestinal bleeding. Immediate follow-up is needed to discontinue NSAIDs and initiate appropriate ulcer management.
Incorrect:
A. Respiratory rate: A rate of 18/min is within the normal range and does not require urgent follow-up.
D. Temperature: A temperature of 37.5°C (99.5°F) is slightly elevated but not clinically significant for immediate intervention.
E. WBC count: The WBC count is within the normal range, making it less of an immediate concern.
Correct Answer is A
Explanation
A) "I should decrease my salt intake to 2 grams per day.":
This statement is correct. For clients with hypertension, a reduced salt intake is essential in managing blood pressure. The general recommendation is to limit sodium intake to less than 2,300 milligrams per day (about 2.3 grams), with an ideal target of 1,500 milligrams per day for individuals with hypertension or those at risk. Reducing salt intake helps lower blood pressure and prevent further complications.
B) "I can have two glasses of wine with dinner.":
This statement is incorrect. While moderate alcohol consumption may not be prohibited, it is important for individuals with hypertension to limit alcohol intake. The American Heart Association recommends no more than one drink per day for women. Two glasses of wine may exceed this limit, which could contribute to an increase in blood pressure.
C) "I should exercise for 5 minutes two times per week.":
This statement is incorrect. Exercise is an important component of managing hypertension, but 5 minutes of exercise twice a week is not sufficient. The general recommendation is for adults to engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week, spread throughout the week. More frequent and longer exercise sessions are necessary to improve cardiovascular health and manage blood pressure.
D) "I will set my blood pressure goal at 130 over 84.":
This statement is incorrect. The goal for blood pressure in individuals with mild hypertension is generally lower than 130/80 mm Hg, according to current guidelines. A blood pressure of 130/84 is still considered elevated. The target should be to maintain a blood pressure below 130/80 mm Hg to reduce the risk of cardiovascular complications.
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