A nurse is caring for a client who is 3 days postoperative following surgical repair of a hip fracture. Which of the following actions should the nurse take to involve the client in decision making?
Report the healing status of the client's surgical site to the provider.
Assist the client to perform exercises and ambulate on the unit.
Consult the client about options proposed by the physical therapist.
Ask the client to their pain on a scale from 0 to 10 every 12 hr.
The Correct Answer is C
A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.
B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.
C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.
D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Position the client on their left side.
This is the most appropriate action. The client's symptoms (dizziness, racing heart, and paleness) are consistent with supine hypotensive syndrome, which occurs when the pregnant uterus compresses the inferior vena cava while lying on the back, reducing venous return to the heart. Positioning the client on their left side relieves the pressure on the vena cava, restores normal blood flow, and alleviates these symptoms. This is a common intervention during pregnancy to prevent such complications.
B) Check the client's temperature.
While checking the client’s temperature may be necessary if an infection is suspected, the symptoms described are more indicative of supine hypotensive syndrome rather than an infection. Therefore, checking the temperature is not the priority action in this scenario.
C) Instruct the client to take a brisk walk.
Encouraging the client to take a brisk walk is not an appropriate response to the symptoms described. In fact, moving or exerting oneself might worsen dizziness or lead to further complications. The priority is to relieve the pressure on the vena cava by changing the client's position, not by physical activity.
D) Provide the client with a glass of orange juice.
Although providing orange juice might help if the client is experiencing hypoglycemia, there is no indication from the symptoms described that the client has low blood sugar. The client's symptoms are more likely due to positional changes that affect circulation during pregnancy, and the best immediate action is to change the client's position rather than offering food or drink.
Correct Answer is ["B","C","E"]
Explanation
A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.
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