A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Tell the client that the surgeon will prescribe restraints if they try to leave.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Administer a sedative medication to the client.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

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Correct Answer is C

Explanation

According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.

It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.

Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.

Choice A is wrong because chlorhexidine is not effective against C. difficile spores.

Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.

Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.

Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.

Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.

Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.

A. “Perform regular isometric exercises.”. B. “Increase your intake of protein.”. C. “Dangle your legs over the side of the bed.”. D. “Use your incentive spirometer.”.

Correct Answer is C

Explanation

The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.

Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.

Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.

These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.

Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.

However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.

Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.

It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is disinfecting the room of a client who has a Clostridium difficultiesinfection. Which of the following solutions should the nurse use?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

Correct Answer is C

Explanation

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?