A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

The correct answers are A, B, and D.

Choice A reason:

Removing an indwelling urinary catheter when it is no longer indicated is a standard postoperative care practice. It helps to reduce the risk of urinary tract infections (UTIs), which are common complications associated with prolonged catheter use. The normal practice is to remove the catheter as soon as the patient can use the bathroom independently or when medically advised.

Choice B reason:

Elevating the affected limb at chest level can help reduce swelling and improve venous return. This is particularly important after surgery involving the lower extremities to prevent edema and promote circulation. Proper elevation assists in managing pain and preventing complications such as deep vein thrombosis (DVT).

Choice C reason:

Assisting with ambulation from bed to chair immediately after surgery may not be appropriate, especially if the adolescent has had surgery on the lower extremity. It is essential to wait for the physician's evaluation and specific instructions regarding weight-bearing and movement post-surgery.

Choice D reason:

Performing neurovascular assessments every hour is crucial after surgery on an extremity. This involves checking for sensation, motor function, color, temperature, capillary refill, and pulse strength. The normal capillary refill time is less than 2 seconds; a refill time of 4 seconds, as noted in the assessment, is abnormal and warrants close monitoring. Frequent assessments help in early detection of complications such as compartment syndrome.

Choice E reason:

Applying warm packs to the right extremity for the first 24 hours post-surgery is not recommended. Warm packs can increase circulation to the area, potentially increasing swelling and bleeding. Instead, cold packs are usually applied to reduce swelling and provide pain relief. The use of warm packs can be considered after the initial 24-hour period, depending on the surgeon's instructions and the wound's response.

Electrolyte imbalance in pregnant clients is often associated with conditions that lead to dehydration and nutritional deficiencies. In this scenario, the key indicators are persistent nausea and significant weight loss.

• Persistent nausea can lead to reduced food and fluid intake. This condition, especially if prolonged, can cause dehydration and electrolyte imbalances due to the loss of essential minerals and nutrients that are not being replenished due to inadequate dietary intake.
• Significant weight loss, particularly the amount described in the scenario (6.8 kg or 15 lb), is a clear sign of inadequate nutritional intake and can further exacerbate the risk of electrolyte imbalance. It indicates that the body is not receiving enough nutrients, which is crucial for maintaining electrolyte balance.

The other options, while related to diet and fluid intake, are more specific to the client's eating habits and do not directly point to the primary cause of potential electrolyte imbalance in the context of this scenario. Therefore, the most comprehensive and medically relevant choice is (A) Persistent nausea and significant weight loss.