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 B
Explanation
Choice A reason: Diarrhea is not typically associated with respiratory alkalosis. It is more commonly related to gastrointestinal issues.
Choice B reason: Hyperventilation is a common finding in respiratory alkalosis. It occurs when a person breathes rapidly and deeply, expelling too much carbon dioxide from the body, which raises the pH of the blood.
Choice C reason: Abdominal pain is not a specific finding related to respiratory alkalosis and can be associated with a variety of health issues.
Choice D reason: Dry skin is not directly related to respiratory alkalosis. While it can be a symptom of various conditions, it does not specifically indicate this type of acid-base imbalance.
Correct Answer is B
Explanation
Choice A reason: Discussing pain management is important for patient comfort but does not directly prevent postoperative complications.
Choice B reason: Sequential compression devices are used to prevent deep vein thrombosis, a common postoperative complication, making this the correct answer.
Choice C reason: Reviewing policy with the client and family is part of the overall care but is not specific to preventing postoperative complications.
Choice D reason: Ensuring the operative site has been secured is a procedural task and does not directly prevent postoperative complications.
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