A nurse working on the postoperative floor has four patients who are scheduled to be discharged tomorrow. Which patient has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care?
A young patient who lives alone, but has nearby family and friends.
An older adult who lives alone at home, despite some memory loss.
A married young adult who is the primary caregiver for children.
A middle-aged patient who has undergone knee replacement and requires physical therapy.
The Correct Answer is B
Choice A rationale:
While a young patient who lives alone may need some assistance with post-discharge care, they have nearby family and friends who can likely provide this support. This patient's situation does not present the same level of complexity and risk as the other patients described in the options.
The presence of nearby family and friends can offer practical and emotional support, helping with tasks such as transportation, meal preparation, and medication management. This social support network can play a crucial role in ensuring a smooth transition from the hospital to home.
Additionally, the patient's young age suggests a higher likelihood of physical and cognitive abilities that can facilitate self-care and adherence to discharge instructions.
Choice B rationale:
The older adult who lives alone and has memory loss has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care. This patient's situation presents several significant challenges that necessitate a collaborative approach to ensure safety and well-being:
Memory loss: The patient's memory loss may impair their ability to follow discharge instructions, manage medications, and maintain personal safety. This raises concerns about potential medication errors, missed appointments, and risks of falls or accidents.
Living alone: The patient's lack of immediate support at home further compounds these risks. Without someone to provide reminders, assistance with tasks, or monitoring for changes in health status, the patient's vulnerability increases.
Potential for social isolation: Living alone with memory loss can also lead to social isolation, which can negatively impact mental and physical health.
Choice C rationale:
While a married young adult who is the primary caregiver for children may face challenges in balancing their own recovery with caregiving responsibilities, they have a spouse who can provide support and assistance. This patient's situation does not present the same degree of risk as the older adult with memory loss living alone.
Choice D rationale:
The middle-aged patient who has undergone knee replacement and requires physical therapy will need support and guidance, but their needs are primarily focused on physical rehabilitation and pain management. These needs can often be addressed through standard discharge planning and coordination with physical therapy services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering an antipyretic would lower the client's fever, but it would not address the underlying cause of the sepsis. Antipyretics can mask important signs and symptoms of infection, making it more difficult to diagnose and treat the sepsis. It's important to identify the causative organism of sepsis to initiate appropriate antibiotic therapy.
Therefore, obtaining cultures to identify the causative organism is the priority action.
Choice B rationale:
Obtaining specified cultures is the most important action for a client with possible sepsis because it allows for the identification of the causative organism.
This information is essential for selecting the appropriate antibiotic therapy. Cultures should be obtained as soon as possible, before antibiotics are administered.
Choice C rationale:
While administering antibiotics is an important part of the treatment for sepsis, it is not the first action that the nurse should take.
Antibiotics should be administered after the causative organism has been identified.
Administering antibiotics before cultures are obtained can make it more difficult to identify the causative organism.
Choice D rationale:
Placing the client in isolation is important to prevent the spread of infection, but it is not the first action that the nurse should take.
The priority is to identify the causative organism and initiate appropriate treatment. The client can be placed in isolation after cultures have been obtained.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Massaging the site with scented oils is not recommended as it may further irritate the inflamed tissue. Additionally, scented oils can cause allergic reactions or skin irritation, worsening the client's discomfort.
Choice B rationale: Applying warm compresses to the site increases blood flow, reduces inflammation, and provides pain relief. Warm compresses also promote healing by improving circulation and reducing edema, making them an appropriate intervention for phlebitis.
Choice C rationale: Administering topical lidocaine to the site is generally not recommended without a prescription. Although it may provide localized pain relief, it can mask underlying issues and delay appropriate medical assessment and treatment.
Choice D rationale: Administering prescribed oral pain medication can provide systemic pain relief. However, it may not be as effective as a localized treatment for reducing inflammation and discomfort at the site of the peripheral vascular access device.
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