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.
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Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is C
Explanation
A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder rather than antisocial personality disorder.
B. Avoids interacting with others: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, but avoidance of social interaction is not a typical
feature.
C. Uses others for personal gain: This behavior aligns with the manipulative and exploitative tendencies often seen in individuals with antisocial personality disorder.
D. Socially awkward in group situations: While individuals with antisocial personality disorder may have difficulty forming meaningful relationships, they often have superficial charm and can be socially adept, so being socially awkward in group situations is less indicative of this disorder.
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