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. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.
B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.
C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.
D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial
damage.
Correct Answer is A
Explanation
A.
A. Art therapist: Art therapy can provide a nonverbal outlet for expressing feelings and emotions, which can be particularly beneficial for clients with schizophrenia who may struggle with verbal communication.
B. Speech-language pathologist: While speech-language pathologists may assist with communication difficulties, their expertise is more focused on speech and language disorders rather than addressing emotional expression in clients with schizophrenia.
C. Social worker: Social workers provide support and assistance with various psychosocial
issues, but they may not specifically address the client's difficulty expressing feelings through therapeutic interventions like art therapy.
D. Recreational therapist: Recreational therapy focuses on promoting leisure and recreational
activities to improve overall well-being, but it may not directly address the client's difficulty with emotional expression.
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