A nurse is caring for a postoperative client following a perineal prostatectomy.

Exhibits

For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Potential Order:.

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

A healthcare surrogate is a person who is authorized to make healthcare decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.
Choice A is wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.
Choice B is wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate.

The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.
Choice C is wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.
The provider is responsible for determining the medical necessity of the surgery and explaining it to the surrogate. The nurse should not question or interfere with the provider’s judgment unless there is evidence of negligence or malpractice.