A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Tell the client that the surgeon will prescribe restraints if they try to leave.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Administer a sedative medication to the client.

None

Answer and Explanation

The Correct Answer is C

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

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Correct Answer is A

Explanation

The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.

This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.

The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.

Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.

Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.

It has no effect on the oxygen saturation level.

Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.

A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.

Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.

The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.

A. Raise the bed to waist level before moving the client. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Stand on the client’s stronger side when moving the client into the chair. D. Flex hips and knees when assisting the client to a standing position.

Correct Answer is D

Explanation

The correct answer is choice D. Flex hips and knees when assisting the client to a standing position.

Choice A rationale:

Raising the bed to waist level before moving the client is not recommended because it can increase the risk of falls and injuries. The bed should be at a height that allows the nurse to maintain proper body mechanics and ensure the client’s safety during the transfer.

Choice B rationale:

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain stability and control during the transfer.

Choice C rationale:

Standing on the client’s stronger side when moving the client into the chair is not the best practice. The nurse should stand on the client’s weaker side to provide support and prevent the client from falling towards their weaker side.

Choice D rationale:

Flexing hips and knees when assisting the client to a standing position is correct. This technique helps the nurse maintain proper body mechanics, reduces the risk of injury, and provides better support to the client during the transfer.

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?