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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin.
B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness.
C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact.
D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.
Correct Answer is D
Explanation
A. "It is my responsibility to obtain informed consent from the client prior to the procedure." is incorrect. It is the provider's responsibility to explain the procedure, its risks, benefits, and alternatives to the client, not the nurse's. The nurse's role is to witness the signing of the consent form.
B. "I will sign the consent form to indicate that the client has received written materials explaining the procedure." is incorrect. The nurse's role is to witness the client's signature, but the nurse does not sign to indicate that the client has received written materials.
C. "I will provide the client with an explanation of the procedure before I sign the consent form." is incorrect. The nurse should not provide the explanation of the procedure; this is the responsibility of the provider. The nurse ensures that the client understands and is signing voluntarily.
D. "When I sign the consent form, I am stating that the client appears to be competent to give consent." is correct. The nurse’s role is to witness the signing of the consent form and ensure that the client appears to be competent to provide consent. The nurse does not provide the explanation but confirms that the client is signing voluntarily and understands the procedure.
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