A nurse is caring for a patient who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the patient hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Keep the bathroom door open to ensure the patient is okay.

Walk the patient back to bed immediately and get the patient a bedpan.

Warn the patient they might have to be restrained if they get up without assistance.

Tell the patient to remain in the bathroom after toileting and obtain a wheelchair.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping the bathroom door open does not address the safety risk of the patient bearing weight on the operative foot.

Choice B reason: While it is important to assist the patient back to bed, providing a bedpan does not address the immediate safety concern.

Choice C reason: Warning the patient about restraints is not appropriate without first educating the patient about the importance of not bearing weight and the potential risks.

Choice D reason: Telling the patient to remain in the bathroom until a wheelchair can be obtained ensures the patient's safety and prevents further weight-bearing on the operative foot.

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Correct Answer is B

Explanation

Choice A reason: A pH of 7.39 is near the lower end of the normal range (7.35-7.45) and would not typically indicate respiratory acidosis.

Choice B reason: A pH of 7.31 is below the normal range, indicating an acidic environment, which is consistent with respiratory acidosis.

Choice C reason: A pH of 7.48 is above the normal range, indicating a more alkaline environment, which would suggest respiratory alkalosis, not acidosis.

Choice D reason: A pH of 7.50 is also above the normal range and would indicate alkalosis rather than acidosis.

A. Discuss pain management with the client. B. Explain the need for sequential compression devices. C. Review the policy with the client and family. D. Ensure the operative site has been secured.

Correct Answer is B

Explanation

Choice A reason: Discussing pain management is important for patient comfort but does not directly prevent postoperative complications.
Choice B reason: Sequential compression devices are used to prevent deep vein thrombosis, a common postoperative complication, making this the correct answer.
Choice C reason: Reviewing policy with the client and family is part of the overall care but is not specific to preventing postoperative complications.
Choice D reason: Ensuring the operative site has been secured is a procedural task and does not directly prevent postoperative complications.

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A nurse is caring for a patient who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the patient hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Nursing Test Bank

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