A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?
A client who has heart failure and is incontinent of urine
A client who has COPD and dementia and was agitated during the night shift
A client who had a hip arthroplasty 10 days ago and reports pain with ambulation
A client who had a cerebrovascular accident 6 months ago and reports constipation
The Correct Answer is B
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
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Related Questions
Correct Answer is B
Explanation
The nurse should include the statement that only health care staff providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.
Explanation for the other options:
a. "Your nurse will provide information about the risks and benefits of surgical procedures." While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.
c. "The provider must grant you access to your personal health information." This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.
d. "You have to authorize our providers to prescribe treatments for your condition." This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.
Correct Answer is A
Explanation
a . Provide a tour of the perioperative area prior to surgery.
The correct answer is a. Provide a tour of the perioperative area prior to surgery.
Explanation:
When caring for an adolescent scheduled for surgery, providing a tour of the perioperative area prior to the procedure is an important action for the nurse to take. Adolescents may experience fear and anxiety related to the unfamiliar environment and procedures associated with surgery. Providing a tour allows the adolescent to become familiar with the surroundings, equipment, and healthcare team, which can help alleviate anxiety and promote a sense of control.
Explanation for the other options:
b. Explain that anesthesia is a special type of sleep: While it is important to provide information about anesthesia to the adolescent, describing it as a "special type of sleep" may be misleading. Anesthesia is a medical procedure that involves more than just being asleep, and it is important to provide accurate information to the adolescent.
c. Keep medical equipment out of the client's sight: While it is important to create a comfortable and non- threatening environment for the adolescent, completely hiding medical equipment may not be feasible or necessary. Instead, the nurse should address any specific fears or concerns the adolescent may have and provide age-appropriate explanations and reassurance.
d. Wait until after surgery to explain the importance of coughing and deep breathing: It is important to provide preoperative education to the adolescent to promote their understanding and cooperation. Explaining the importance of coughing and deep breathing before surgery helps the adolescent prepare and participate in their own recovery. Waiting until after surgery may result in missed opportunities for early postoperative interventions.
In summary, providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control.
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