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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
Determine the total daily dose required in milligrams:
The prescribed dose is 80 mg/kg/day.
The child's weight is 35 kg.
Totaldailydose=80mg/kg/day×35kg
Calculate the total daily dose:
Totaldailydose=2800mg/day
Divide the total daily dose into four doses:
Doseperadministration: 2800mg/day ÷ 4 =700mg
Determine the volume of the oral suspension to administer per dose:
The available concentration of sucralfate oral suspension is 1 g/10 mL.
Convert 1 g to mg:
1g=1000mg.
Calculate the volume needed for 700 mg:
Volume(mL) = Desireddose(mg)÷Concentration(mg/mL)
Concentration = 1000mg÷10mL = 100mg/mL
Volume(mL) = 700 mg ÷ 100mg/mL
= 7 mL
Therefore, the nurse should administer 7 mL of sucralfate oral suspension per dose.
Correct Answer is C
Explanation
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
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