A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

Call the pharmacy to see which medications should be taken.

Verify that a follow-up appointment has been scheduled.

Notify the healthcare provider (HCP) if a fever develops.

Use movement techniques taught by the physical therapists.

Answer and Explanation

The Correct Answer is A

A. Call the pharmacy to see which medications should be taken indicates a misunderstanding of discharge instructions. The client should already have a clear understanding of their prescribed medications before discharge, including dosage, timing, and purpose. This responsibility lies with the healthcare provider or nurse, not the pharmacy, and the nurse should provide additional clarification.

B. Verify that a follow-up appointment has been scheduled is appropriate and demonstrates that the client understands the importance of follow-up care to monitor recovery and address any complications.

C. Notify the healthcare provider (HCP) if a fever develops is a correct action, as fever may indicate infection, a common postoperative complication that requires prompt attention.

D. Use movement techniques taught by the physical therapists reflects proper understanding of postoperative mobility instructions, which are crucial for preventing complications such as blood clots and for supporting recovery.

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Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Reduce the stimuli in the area before continuing the teaching. B. Reassure the client that the skill is not difficult to learn. C. Provide the client with step-by-step written instructions. D. Demonstrate the skill, speaking slowly and using simple terms.

Correct Answer is A

Explanation

A. Reduce the stimuli in the area before continuing the teaching is the best action. Sensory overload can interfere with a client's ability to learn effectively. By reducing distractions and environmental stimuli, the nurse can create a more conducive learning environment.

B. Reassure the client that the skill is not difficult to learn may be helpful, but it does not address the immediate issue of sensory overload. The client needs to be in an environment where they can focus and process information before reassurance is effective.

C. Provide the client with step-by-step written instructions may be helpful later, but in the context of sensory overload, the priority is to first reduce the stimuli. Written instructions can be given once the client is in a calmer state.

D. Demonstrate the skill, speaking slowly and using simple terms is a helpful teaching strategy, but if the client is experiencing sensory overload, the first step should be to reduce the environmental stimuli. Once the environment is conducive to learning, the nurse can proceed with demonstrating the skill.

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A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

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Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is A

Explanation

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