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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Educating the client on covering the nose and mouth with tissues when coughing helps prevent the spread of tuberculosis by containing respiratory secretions.
B. A client with active tuberculosis should not return to work until they have completed a sufficient duration of treatment and are deemed non-infectious, not solely based on negative sputum cultures.
C. The client remains contagious until they have been on appropriate medication therapy for a sufficient duration and are deemed non-infectious by healthcare providers, usually after several weeks of treatment rather than just one week.
D. While wearing protective masks may be recommended for healthcare workers or individuals with compromised immune systems, it's not necessary for the client's family members unless they are in close contact with the client for an extended period.
Correct Answer is A
Explanation
A.
A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.
B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.
C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.
D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.
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