A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

Recommend occupational therapy referral for the client.

Reinforce teaching about the client's prescribed medications.

Provide the client with a list of community resources.

Encourage the client to discuss nutritional needs with a dietitian.

Answer and Explanation

The Correct Answer is A

A) Recommend occupational therapy referral for the client: This is the priority action because the client is experiencing difficulty with activities of daily living (ADLs) due to left-sided weakness following a cerebrovascular accident. Occupational therapy focuses on improving the client's ability to perform ADLs and regain independence. Referring the client to occupational therapy is essential for maximizing functional ability and promoting recovery.

B) Reinforce teaching about the client's prescribed medications: While medication education is important for overall health management, it is not the priority in this situation. The client's immediate need is assistance with ADLs to address functional deficits resulting from the cerebrovascular accident.

C) Provide the client with a list of community resources: Community resources may be beneficial for the client's long-term care and support, but addressing the immediate need for assistance with ADLs takes precedence. Referring the client to occupational therapy will address the functional limitations more directly and effectively.

D) Encourage the client to discuss nutritional needs with a dietitian: Nutritional needs are important for overall health and recovery, but addressing the client's physical limitations and ADLs is the priority at this time. Once the client's ability to perform ADLs improves, discussions about nutrition can follow as part of a comprehensive care plan.

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Correct Answer is D

Explanation

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

A. Reinforcing teaching with a client about stool specimen collection B. Collecting a urine specimen from a client who is experiencing dysuria C. Taking the vital signs of a client who is experiencing acute angina D. Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Correct Answer is B

Explanation

A) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

C) Taking the vital signs of a client who is experiencing acute angina:

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.

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