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 A
Explanation
A) "My baby will receive the rotavirus immunization orally.":
This statement is correct. The rotavirus vaccine is given orally in two or three doses depending on the specific vaccine used (Rotarix or RotaTeq). The vaccine is administered in the mouth and helps protect against rotavirus infections, which can cause severe diarrhea in infants and young children.
B) "I should expect my baby to have a high fever for 24 hours after an immunization.":
This statement is incorrect. While it is common for infants to experience mild side effects after immunizations, such as a low-grade fever or irritability, a high fever is not typically expected. If the baby develops a high fever (above 100.4°F), the guardian should seek advice from the healthcare provider, as it could indicate a reaction or infection.
C) "I should not feed my baby anything for hours prior to an immunization.":
This statement is incorrect. There is no need to withhold feeding before an immunization, and the baby should be fed as usual. In fact, feeding the infant before the appointment may help comfort them and reduce stress during the visit.
D) "My baby will receive three doses of the meningococcal immunization before kindergarten.":
This statement is incorrect. The meningococcal vaccine is typically administered starting at age 11, with a second dose given at age 16. For infants and young children, the vaccine is not part of the routine immunization schedule. Meningococcal vaccination before kindergarten is not recommended for infants at 2 months of age.
Correct Answer is C
Explanation
A) Occasional small clots in the urine:
Occasional small clots can be expected after a transurethral resection of the prostate (TURP) due to the surgical trauma to the prostate and surrounding tissues. However, any change in the nature or frequency of clots, or if they become larger, should be reported, but small clots are not immediately concerning in the early postoperative period.
B) Urine output of 300 mL over 8 hr:
This urine output is within a reasonable range. While urine output may be initially monitored closely after TURP, a volume of 300 mL over 8 hours does not constitute a concerning finding. It may be less than expected, but it is not an emergency. The nurse should continue to monitor urine output, but this is not immediately concerning unless the client has a significantly reduced or absent output.
C) Dark red urine:
Dark red urine is a concerning finding as it may indicate excessive bleeding or hemorrhage, especially within the first 24 hours after TURP. While some initial hematuria (blood in the urine) is common, the urine should not remain dark red or worsen. This could indicate active bleeding or a clot obstructing the urinary flow, which requires immediate intervention and reporting to the healthcare provider to prevent complications.
D) Frequent urge to urinate:
A frequent urge to urinate is not an unusual finding following TURP, as the bladder may be irritated due to the catheter or residual inflammation from the surgery. While it is a discomforting symptom, it is typically not an immediate concern and often resolves as the healing process progresses. However, persistent or painful urination may require further evaluation.
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