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) *Once you have completed a living will, it cannot be changed: This statement is inaccurate. A living will can be revised or updated at any time while the client is still capable of making decisions. The client can amend or revoke their living will if they change their mind about their wishes regarding end-of-life care or other medical decisions.

B) "You will need an attorney to appoint a health care surrogate": This statement is incorrect. While legal assistance might be beneficial in some cases, it is not required to appoint a health care surrogate. The appointment can typically be done through a simple form provided by the facility, and it is not necessary to hire an attorney for this process.

C) "You should appoint a family member as your health care surrogate": While appointing a family member as a health care surrogate is common, it is not a requirement. The person appointed should be someone who understands the client’s wishes and will act in the client's best interest. It is important to select someone who can make tough decisions, but it
doesn’t have to be a family member.

D) "Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate is a person appointed to make medical decisions on behalf of the client if they are unable to do so themselves due to incapacity. This role is critical when the client cannot communicate their wishes due to illness or injury.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

B. A chest X-ray: The client’s symptoms (cough, blood-tinged sputum, night sweats, fever, and weight loss) are concerning for tuberculosis (TB) or another pulmonary infection. A chest X-ray is a key diagnostic tool to assess for lung abnormalities, including TB infiltrates or cavitations.

D. A Mantoux test: The Mantoux tuberculin skin test (TST) is used to screen for Mycobacterium tuberculosis infection. Given the client’s recent travel to South Africa, a high TB prevalence area, and their symptoms, TB testing is crucial.

Incorrect:

A. A pulmonary function test: This evaluates chronic respiratory conditions like asthma or COPD, but is not a first-line test for an acute cough with systemic symptoms.

C. A nasopharyngeal swab: This is used for diagnosing viral infections like influenza or COVID-19, which are less likely given the client’s blood-tinged sputum and prolonged systemic symptoms.

E. Blood cultures: These are used to detect bacteremia or sepsis, but there is no indication of systemic bacterial infection (e.g., hemodynamic instability, severe leukocytosis).

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

Select words from the choices below to fill in each blank in the following sentence. To further evaluate the client, the nurse anticipates the client will need ____ and ____ .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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