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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.
B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.
C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.
D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.
Correct Answer is C
Explanation
A. Thrombocytopenia: Neither atenolol nor nitroglycerin is commonly associated with thrombocytopenia. This is not the primary concern when these two medications are used together.
B. Dry cough: A dry cough is a known side effect of ACE inhibitors (e.g., enalapril), but it is not commonly associated with atenolol or nitroglycerin.
C. Hypotension: Both atenolol (a beta-blocker) and nitroglycerin (a vasodilator) can lower blood pressure. When taken together, there is an increased risk of hypotension, especially when standing up quickly. The nurse should monitor the client for symptoms of low blood pressure such as dizziness, fainting, or lightheadedness.
D. Hyperglycemia: Atenolol may mask signs of hypoglycemia in clients with diabetes, but it does not directly cause hyperglycemia. Nitroglycerin is not typically associated with hyperglycemia either. Therefore, hyperglycemia is not a concern in this scenario.
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