An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD. and peripheral vascular disease (PVD. is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?
Reinforce need for adequate hydration.
Provide typed instructions for healthy diet selection.
Schedule follow-up appointments with specialists.
Demonstrate specific breathing and walking exercises.
The Correct Answer is C
Choice A: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.
Choice B: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.
Choice C: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.
Choice D: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: An adult client with a tracheal tube draining clear, pale red liquid drainage. This client should not be assessed last, as they may have a potential airway obstruction or infection. The tracheal tube drainage should be monitored for color, amount, and consistency, and suctioned as needed.
Choice B: An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. This client should not be assessed last, as they may have a potential hemorrhage or wound dehiscence. The postoperative dressing and Hemovac should be monitored for color, amount, and odor, and changed as needed.
Choice C: An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client can be assessed last, as they have no signs of complications or problems. The Jackson-Pratt drain is a closed suction device that collects fluid from a surgical site. The bulb should be compressed to create negative pressure and facilitate drainage.
Choice D: An older client with a distended abdomen and no drainage from the nasogastric tube. This client should not be assessed last, as they may have a potential bowel obstruction or perforation. The nasogastric tube is inserted through the nose into the stomach to decompress gas and fluid. The abdomen should be monitored for size, shape, and bowel sounds, and the nasogastric tube should be checked for patency and placement.
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
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