A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

Assist with a referral to a home health care agency.

Call the provider about admitting the client to the facility overnight.

Give the client a list of home care assistants to contact.

Contact the next of kin to assist the client at home.

Answer and Explanation

The Correct Answer is A

A. Assist with a referral to a home health care agency is correct. If the client has no one to assist them at home after surgery, a home health care agency can provide the necessary support. This is a proactive solution to ensure the client has assistance for postoperative recovery, including monitoring for complications, assistance with mobility, and other care needs.

B. Calling the provider about admitting the client to the facility overnight is incorrect. Outpatient surgery is typically intended for clients who can recover at home, and there is no indication that the client requires overnight admission based solely on the lack of assistance at home.

C. Giving the client a list of home care assistants to contact is incorrect. While this could be helpful, it is the nurse's role to actively assist in arranging care. Referring the client to a list of names without offering concrete help may leave the client in a challenging situation.

D. Contacting the next of kin to assist the client at home is incorrect. Although contacting a relative may be an option, it may not be viable or practical for the client. Home health care offers a more reliable solution, as family members may not always be available to provide consistent care.

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Correct Answer is A

Explanation

A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.

B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.

C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.

A. This medication will increase the immunity of your newborn. B. This medication will decrease the risk of hemorrhage in your newborn. C. This medication will decrease the possibility of your newborn developing jaundice. D. This medication will increase the absorption of nutrients in the intestines.

Correct Answer is B

Explanation

A. This medication will increase the immunity of your newborn.: Vitamin K does not directly affect the immunity of a newborn. It plays a crucial role in blood clotting, not immune function.

B. This medication will decrease the risk of hemorrhage in your newborn.: Vitamin K is given to newborns to prevent bleeding or hemorrhagic disease, as newborns have low levels of vitamin K at birth, which is essential for clotting.

C. This medication will decrease the possibility of your newborn developing jaundice.: Vitamin K does not have a role in preventing jaundice, which is related to elevated bilirubin levels in the blood.

D. This medication will increase the absorption of nutrients in the intestines.: Vitamin K does not influence nutrient absorption in the intestines; it primarily supports blood clotting by helping in the synthesis of clotting factors.

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A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has left-sided heart failure. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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