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.

Answer and Explanation

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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Correct Answer is D

Explanation

A) Withhold the medication if pulse rate is less than 60/min: Enalapril, an ACE inhibitor, primarily affects blood pressure and does not typically require withholding based on pulse rate alone. Withholding enalapril is not recommended unless instructed by the healthcare provider for other reasons, such as a significant drop in blood pressure. The issue at hand is likely related to orthostatic hypotension rather than pulse rate.

B) Increase dietary potassium: Enalapril can increase potassium levels in the blood due to its effect on the renin-angiotensin system, potentially leading to hyperkalemia. Clients should avoid excessive potassium intake, especially through supplements or potassium-rich foods, unless advised by their healthcare provider. Increasing potassium may exacerbate any existing risks.

C) Decrease daily fluid intake: Decreasing fluid intake is not a recommended intervention for managing syncope related to enalapril. In fact, reducing fluid intake can exacerbate dehydration or low blood pressure, potentially worsening symptoms. Adequate hydration is typically important for managing blood pressure and syncope risk.

D) Rise slowly from a sitting position to a standing position: This is the most appropriate
advice. Enalapril can cause orthostatic hypotension, a condition in which blood pressure drops when changing positions (such as from sitting to standing). This can lead to dizziness or syncope. Rising slowly from a sitting position helps prevent a sudden drop in blood pressure and reduces the risk of fainting. Clients should be instructed to take this precaution until the body adjusts to the medication’s effects.

A. Tape the tube to the child's cheek. B. Secure the tubing to the child's abdomen. C. Apply water-soluble lubricant to the site. D. Attach an extension tube to the site's opening prior to use.

Correct Answer is B

Explanation

A) "Tape the tube to the child's cheek."
Taping the tube to the child's cheek is not appropriate for securing a gastrostomy enteral tube. The tube should be securely anchored to the child's abdomen to prevent dislodgment or irritation. Taping to the cheek can lead to unnecessary friction or skin breakdown.

B) "Secure the tubing to the child's abdomen."
The proper method to secure a gastrostomy tube is to anchor the tubing to the child’s abdomen with a specialized securing device or adhesive bandage. This ensures the tube remains in place, minimizing movement and preventing irritation or accidental removal. Proper securing also promotes comfort and safety for the child.

C) "Apply water-soluble lubricant to the site."
Water-soluble lubricant should not be applied directly to the gastrostomy site. This can cause irritation or create a barrier that inhibits proper healing. Instead, the site should be kept clean and dry, with appropriate care to prevent infection or breakdown.

D) "Attach an extension tube to the site's opening prior to use."
While attaching an extension tube may be necessary for feeding or drainage, this action is not related to site care. The focus of site care is to ensure the gastrostomy tube remains securely in place, and the skin around the site is maintained without infection or irritation. Extension tubes are used for feeding or medication administration, not for routine site care.

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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?

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Correct Answer is B

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