A nurse is caring for a client with limited mobility due to recent surgery. What is the most appropriate intervention to ensure the client's personal hygiene needs are met?
Assess the client's ability and assist with tasks they cannot perform
Focus only on oral hygiene as it is the most important aspect of personal care.
Encourage the client to perform all hygiene tasks independently
Provide full assistance with hygiene tasks without involving the client.
The Correct Answer is A
A. Assess the client's ability and assist with tasks they cannot perform: Individualized assessment allows the nurse to determine which hygiene activities the client can safely perform and where assistance is needed. This approach promotes independence, preserves dignity, and prevents complications such as skin breakdown. It aligns with patient-centered care and postoperative recovery principles.
B. Focus only on oral hygiene as it is the most important aspect of personal care: Oral hygiene is important, but neglecting other aspects such as skin care, perineal care, and bathing increases the risk of infection and impaired comfort. Comprehensive hygiene is necessary for overall health. Limiting care to one area is inadequate.
C. Encourage the client to perform all hygiene tasks independently: While independence is encouraged, recent surgery and limited mobility may make some tasks unsafe or impossible. Forcing independence can increase fatigue, pain, or risk of injury. Nursing care should balance support with autonomy.
D. Provide full assistance with hygiene tasks without involving the client: Performing all hygiene tasks without involving the client reduces independence and can negatively affect self-esteem. Participation promotes mobility, circulation, and a sense of control. Total care is not indicated unless the client is completely dependent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Request specific recommendations from the provider: This step occurs later during the Recommendation portion of ISBARR. At the beginning of the communication, the nurse must first clearly state why the call is urgent before asking for orders or guidance.
B. Describe the current client condition and critical changes requiring attention: After identification, the Situation is prioritized to immediately communicate what is happening now. This ensures the provider quickly understands the urgency related to deteriorating vital signs.
C. Read back the orders given by the provider for clarification: Read-back occurs at the end of the communication to confirm accuracy of orders. It is not appropriate until recommendations have been made and instructions received.
D. Provide detailed background information including medical history: Background information follows the situation and should be concise. Providing extensive history too early can delay recognition of a life-threatening change in the client’s condition.
Correct Answer is C
Explanation
A. Notify the provider immediately and prepare for potential intervention: While tachycardia may signal complications such as bleeding or infection, immediate notification without verification may be premature. The nurse should first confirm the accuracy of the reading.
B. Reassess the pulse in one hour and document the findings: Waiting an hour before reassessment risks delaying recognition of a potentially serious complication. Tachycardia post-surgery warrants prompt verification and assessment rather than delayed monitoring.
C. Perform a manual pulse check and compare it with the monitor reading: Verifying the heart rate manually ensures accuracy and helps identify false readings due to artifact, movement, or monitor malfunction. This is the safest initial action before determining further interventions.
D. Administer pain medication to decrease the pulse rate: Tachycardia may be caused by pain, but it could also indicate hypovolemia, infection, or other post-surgical complications. Administering medication without assessment could mask symptoms and delay treatment of the underlying cause.
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