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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Hot cocoa: Hot cocoa contains the least amount of caffeine compared to the other beverages listed. While it does contain some caffeine, it is significantly lower than coffee, tea, or cola. A typical 8 oz serving of hot cocoa contains approximately 3-10 mg of caffeine, making it the best option for a client looking to reduce caffeine intake.

B) Brewed green tea: Brewed green tea contains more caffeine than hot cocoa. On average, an 8 oz cup of brewed green tea contains about 25-30 mg of caffeine, which is more than cocoa but less than coffee or cola. Although green tea has health benefits, it may not be the best option for those trying to limit caffeine intake.

C) Instant coffee: Instant coffee typically contains more caffeine than brewed green tea or hot cocoa. An 8 oz serving of instant coffee can contain around 30-90 mg of caffeine, depending on the brand and how it is prepared. While it provides a caffeine boost, it is not a good choice for someone seeking to reduce caffeine consumption.

D) Cola soft drink: Cola soft drinks contain a moderate amount of caffeine, usually about 30 mg per 8 oz serving. While this is less than coffee or tea, it still contains more caffeine than hot cocoa and could be a concern for someone trying to cut back on caffeine.

A. Insert an oral airway into the client’s mouth B. Measure the duration of the seizure. C. Lower the side rails of the bed when the seizure begins. D. Restrain the client's arms and legs to prevent injury. E. None F. None

Correct Answer is B

Explanation

A. Attempting to force an object into the oral cavity during muscle contraction causes dental trauma or jaw fractures. It significantly increases the risk of aspiration if the object breaks or triggers a gag reflex. Modern clinical guidelines strictly prohibit the insertion of any device into the mouth during active convulsions. Airway patency is maintained by placing the client in a lateral position.

B. Tracking the exact duration of the ictal phase is a critical nursing responsibility for clinical assessment. This data determines the necessity for emergency benzodiazepines if the event lasts longer than 5 minutes. Precise timing helps differentiate between a self-limiting seizure and dangerous status epilepticus. The nurse must record the start and end times to guide medical intervention.

C. Lowering the side rails during a seizure increases the risk of the client falling from the height of the bed. Standard seizure precautions require that side rails remain raised and should be padded to prevent blunt force trauma. Ensuring the patient stays within the safe boundaries of the bed is a primary safety goal.

D. Physical restraints can cause severe musculoskeletal injuries such as fractures or dislocations during the forceful involuntary movements of the clonic phase. Restricting the extremities creates unnecessary resistance against powerful muscle contractions. The nurse should clear the immediate area of hard objects rather than holding the client down.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Correct Answer is B

Explanation

A nurse in a mental health facility caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is assisting in the care of a client Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse is assigned to care for several clients on a mental health unit. One of the clients who has suicidal ideation starts to verbalize clear intent to self harm. Which of the following actions should the nurse take?

A nurse is assisting in the care of a newly admitted client. Which of the following findings should the nurse report immediately to the provider? Select all that apply

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation ofhyperkalemia?

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?