An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client?
The client will use self-affirmation statements to decrease fear.
The client will ambulate with assistance for q4 hours.
The physical therapist will instruct the client in the use of a walker.
The PN will place a gait belt on the client prior to ambulation.
The Correct Answer is B
While all of the options address the issue of impaired mobility related to fear of falling, the desired outcome of ambulating with assistance q4 hours is the most specific and measurable goal. This outcome focuses on promoting mobility and addressing the client's fear of falling by providing the necessary assistance during ambulation. It ensures that the client is engaging in regular activity and working towards regaining mobility.
The other options address different aspects of the nursing problem:
A. "The client will use self-affirmation statements to decrease fear" is a potential intervention that can be used to address the client's fear of falling, but it does not directly address the issue of impaired mobility.
C. "The physical therapist will instruct the client in the use of a walker" is an intervention that can be helpful in improving mobility, but it does not specify the frequency or timing of ambulation.
D. "The PN will place a gait belt on the client prior to ambulation" is a specific intervention that ensures the safety of the client during ambulation, but it does not address the frequency or timing of ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.
Choice A: Paper tape
Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.
Choice B: Small gauze pad
Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.
Choice C: Sterile gloves
Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.
Choice D: Exam gloves
Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.
Choice E: Three mL syringe
Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.
Correct Answer is C
Explanation
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admitted with complications of left-sided heart failure.
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