A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?

Provide the client with a walker.

Premedicate the client with the prescribed analgesic.

Obtain the client's vital signs and oximetry prior to ambulation.

Reinforce the client's surgical dressing.

Answer and Explanation

The Correct Answer is C

A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.

B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.

C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.

D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical

incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.

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Correct Answer is D

Explanation

A. Prohibiting visitors is not necessary for clients with sealed internal radiation implants. Visitors should be allowed unless specific restrictions are required based on the type of radiation therapy.

B. While maintaining distance from the radiation source is important, there is no specific guideline stating a 3-foot distance. The nurse should follow institutional policies and radiation safety guidelines regarding proximity to the radiation source.

C. There is no need to maintain the client on bed rest for 72 hours after receiving a sealed

internal radiation device. The client should be encouraged to ambulate and perform activities of daily living as tolerated.

D. Requiring the client to wear a dosimeter badge allows healthcare providers to monitor the amount of radiation exposure received by the client and ensures that radiation safety protocols are followed.

A. Failure to engraft B. Veno-occlusive disease C. Graft-versus-host disease D. Pancytopenia

Correct Answer is B

Explanation

A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.

B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.

C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.

D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.

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