A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The correct answer is Constipation / Opioid use.
Constipation is a common side effect of opioid use. The client is receiving oxycodone for pain management, which can slow down the digestive system, leading to constipation.
Pressure injuries, also known as pressure ulcers or bedsores, are a risk due to prolonged immobility. This is especially relevant for a client who is postoperative and has limited movement. However, this was not selected as the primary condition based on the given clues.
Hypoglycemia (low blood sugar) is not directly indicated by the client's current medications or conditions. The client is receiving IV dextrose, but there is no indication of a risk of hypoglycemia in the provided information.
Confusion can occur in clients with cognitive impairments or due to medication side effects, but it is not specifically indicated as a primary risk in this case.
Dysrhythmias (abnormal heart rhythms) can be caused by imbalances in potassium or sodium levels, among other factors, but there is no evidence of such imbalances or related symptoms in this client’s case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
"Tell me more about what happens at mealtime.”. This response encourages the caregiver to share detailed information about mealtime routines and behaviors, which can help the nurse identify underlying issues and suggest appropriate strategies.
Choice B rationale
"They may need a feeding tube.”. This suggestion can be alarming and may not be appropriate without understanding the full context of the client's eating habits. Feeding tubes are considered only when other interventions have failed.
Choice C rationale
"Have you tried offering different foods?" While this might be helpful, it does not address the underlying issues. Gathering more information about the current mealtime situation is crucial before suggesting specific interventions.
Choice D rationale
"Let's discuss ways to encourage their appetite.”. This response is proactive but still doesn't gather enough information about the current situation. Understanding the specifics of mealtime behavior is necessary to provide tailored advice.
Correct Answer is C
Explanation
Choice A rationale
Documenting the refusal in the client's medical record is important for legal and clinical reasons, ensuring there's a record of the client's decision and the nurse's response. However, it doesn't address the client's immediate concerns or needs.
Choice B rationale
Returning the medication to the medication cabinet is a necessary step to ensure medication safety and avoid accidental administration. Yet, it does not address the client's reasons for refusal or the potential risks involved.
Choice C rationale
The nurse’s first action should be to provide client education about the importance of taking the medication and the potential consequences of refusal (e.g., increased blood pressure, risk of stroke or heart attack). Addressing the client’s concerns about side effects can encourage adherence or lead to an alternative treatment plan.Client autonomy is respected, but ensuring informed refusal is part of the nurse’s role.
Choice D rationale
The provider should be informed, but only after the nurse has attempted to educate and address the client’s concerns. The provider may adjust the prescription if side effects are problematic.
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