A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive.
Which of the following actions should the nurse take?
Facilitate an interdisciplinary conference at the new facility for the family
Refer the client and family to a social worker for assistance and a follow-up meeting
Reassure the client's family that the same provider will provide care at the new facility
Tell the family that the rehabilitation facility has an excellent client care record
The Correct Answer is A
- A is correct because facilitating an interdisciplinary conference at the new facility for the family can help address their concerns, provide information about the client's plan of care, and promote continuity of care.
- B is incorrect because referring the client and family to a social worker for assistance and a follow-up meeting is not enough to address their immediate concerns and does not involve other members of the health care team.
- C is incorrect because reassuring the client's family that the same provider will provide care at the new facility may not be true and does not address their specific concerns about the level of care.
- D is incorrect because telling the family that the rehabilitation facility has an excellent client care record is not enough to address their specific concerns and may sound dismissive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
Correct Answer is D
Explanation
- A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.
- B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.
- C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.
- D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.
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