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 C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

A. Record a palpable systolic pressure of 90 mm Hg. B. Inflate blood pressure cuff to 120 mm Hg. C. Release the manometer valve immediately. D. Document the absence of the radial pulse.

Correct Answer is B

Explanation

A. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure.

B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure.

C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse.

D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Correct Answer is C

Explanation

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

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