A nurse is caring for a patient who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the patient hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?
Keep the bathroom door open to ensure the patient is okay.
Walk the patient back to bed immediately and get the patient a bedpan.
Warn the patient they might have to be restrained if they get up without assistance.
Tell the patient to remain in the bathroom after toileting and obtain a wheelchair.
The Correct Answer is D
Choice A reason: Keeping the bathroom door open does not address the safety risk of the patient bearing weight on the operative foot.
Choice B reason: While it is important to assist the patient back to bed, providing a bedpan does not address the immediate safety concern.
Choice C reason: Warning the patient about restraints is not appropriate without first educating the patient about the importance of not bearing weight and the potential risks.
Choice D reason: Telling the patient to remain in the bathroom until a wheelchair can be obtained ensures the patient's safety and prevents further weight-bearing on the operative foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevating the patient in a high Fowler's position can help improve lung expansion and oxygenation, and using an incentive spirometer along with coughing can help prevent atelectasis and pneumonia, which are common postoperative complications.
Choice B reason: Increasing oxygen to 70% without a specific indication could lead to oxygen toxicity, especially without assessing the patient's current oxygenation status.
Choice C reason: Switching to a rebreather mask is not indicated based on the given ABG results and could lead to CO2 retention.
Choice D reason: Positioning the patient prone and performing postural drainage are not typically first-line interventions for a patient one day post-thoracotomy and could be contraindicated due to the recent surgery.
Correct Answer is D
Explanation
Choice A reason: While opioids can lower blood pressure, it is not as common as respiratory depression.
Choice B reason: Causing drowsiness is a common side effect of opioids, but it is less critical than respiratory effects.
Choice C reason: Opioids do not typically induce a cough; they may actually suppress coughing.
Choice D reason: Opioids can slow the respiratory rate, which is a critical side effect that nurses must monitor for and educate patients about.
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