The nurse is caring for a client who has had surgery and has been confined to bed for the past 3 days. The nurse is preparing to get the client out of bed for the first time.
What precautionary measure will the nurse take when getting this client up?
Place anti-embolism stockings on the client after the client gets out of bed.
Assist client to sit and dangle the feet over the bed before standing up.
Place the client in a semi-Fowler's position for 30 minutes before getting the client out of bed.
Stand the client at the bedside and allow the client to walk only to the chair.
The Correct Answer is B
Choice A rationale
Anti-embolism stockings are designed to provide graduated compression to the lower extremities to promote venous return and prevent deep vein thrombosis. However, these stockings must be applied while the client is still in a recumbent position before they ever get out of bed. Applying them after the client has already stood up is ineffective because blood may have already pooled in the lower extremities, which increases the risk of clot formation and vascular strain.
Choice B rationale
Assisting the client to dangle their feet over the bedside allows the cardiovascular system to adjust to gravity after prolonged periods of horizontal bed rest. This prevents orthostatic hypotension, which is a drop in blood pressure that occurs when standing up too quickly. A normal blood pressure is typically around 120÷80 mmHg. By dangling, the nurse ensures the client does not experience dizziness or syncope, which could lead to a dangerous fall during the first ambulation.
Choice C rationale
Placing the client in a semi-Fowler's position involves elevating the head of the bed to an angle between 30 and 45 degrees. While this position is helpful for respiratory expansion and comfort, it does not sufficiently challenge the baroreceptor reflex needed for standing. It is a passive transition that does not provide the necessary step of dependent positioning for the legs. Therefore, it is an insufficient precautionary measure compared to the active step of dangling at the bedside.
Choice D rationale
Standing the client and immediately walking them to a chair is dangerous for a client who has been bedridden for three days. The sudden transition from lying down to standing can cause a rapid decrease in cerebral perfusion. The nurse must first evaluate the client's tolerance and stability while they are still supported by the bed. Moving directly to walking without a transition phase significantly increases the risk of injury for both the client and the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Wound drainage is a significant clinical sign of localized infection, especially when it is purulent or malodorous. While it provides evidence of the body's inflammatory response to pathogens, it remains a localized finding in this specific assessment. The presence of drainage alone does not immediately indicate systemic involvement as clearly as a significant change in core body temperature or other vital signs. Therefore, it is concerning but secondary to the signs indicating that the infection may be becoming systemic.
Choice B rationale
Platelet count monitoring is necessary to evaluate the client's ability to maintain hemostasis and respond to inflammation. In the context of infection, platelets can sometimes decrease if disseminated intravascular coagulation occurs or increase as an acute phase reactant. However, without a specific lab value provided in this question, it remains a theoretical concern. It does not take precedence over the actual, measured elevation in body temperature which is already currently present and indicating a systemic physiological response.
Choice C rationale
Subjective report of pain is a key indicator of tissue integrity and the inflammatory response. The client's pain level of 5/10 reflects moderate discomfort likely caused by edema and pressure from the infected wound. While pain management is a core nursing responsibility, pain is a symptom rather than a life-threatening physiological instability. In the hierarchy of clinical cues, a subjective pain score is generally prioritized lower than objective vital sign abnormalities that suggest a systemic infectious process.
Choice D rationale
Elevated body temperature of 101.4 F (38.6 C) is the most concerning cue because it suggests the infection is no longer localized and has triggered a systemic inflammatory response. Normal body temperature is approximately 98.6 F (37 C). Fever, combined with the client's report of malaise and fatigue, indicates that the wound infection may be progressing toward sepsis. This systemic manifestation requires immediate intervention, including blood cultures and potential intravenous antibiotics, to prevent further clinical deterioration and organ dysfunction.
Correct Answer is C
Explanation
Choice A rationale
Taking a fire extinguisher to the room follows the acronym PASS, but in the sequence of fire safety represented by the acronym RACE, extinguishing the fire is the very last step. The nurse must first ensure that the alarm is sounded to alert the entire facility and the fire department. Attempting to fight a fire before the alarm is activated could lead to the fire spreading unnoticed by others, which puts the entire building and all occupants at risk.
Choice B rationale
While calling 911 is an important part of emergency response, pulling the fire alarm is a faster and more efficient way to alert all personnel in a hospital setting. The fire alarm system is often directly linked to the fire department and simultaneously activates internal alerts and fire doors. Relying solely on a phone call may delay the immediate localized response needed to contain the situation. The alarm ensures that the specific location of the fire is identified.
Choice C rationale
According to the RACE acronym, which stands for Rescue, Alarm, Confine, and Extinguish, the second action after rescuing the client is to activate the fire alarm. This ensures that the fire department is notified and that all staff members are aware of the emergency. Promptly pulling the alarm allows the facility to begin its established fire protocols, which are essential for the safety of everyone in the building. It is the most critical next step.
Choice D rationale
Evacuating all clients on the nursing unit is a later step in the fire safety protocol, typically occurring if the fire cannot be contained or if ordered by the fire marshal. The immediate priority after removing the person in danger is to sound the alarm. Evacuation is a complex and high-risk process that should be coordinated based on the severity and location of the fire. Moving too many people prematurely can create chaos and block the access of emergency responders.
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