A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

Assist with a referral to a home health care agency.

Call the provider about admitting the client to the facility overnight.

Give the client a list of home care assistants to contact.

Contact the next of kin to assist the client at home.

Answer and Explanation

The Correct Answer is A

A. Assist with a referral to a home health care agency is correct. If the client has no one to assist them at home after surgery, a home health care agency can provide the necessary support. This is a proactive solution to ensure the client has assistance for postoperative recovery, including monitoring for complications, assistance with mobility, and other care needs.

B. Calling the provider about admitting the client to the facility overnight is incorrect. Outpatient surgery is typically intended for clients who can recover at home, and there is no indication that the client requires overnight admission based solely on the lack of assistance at home.

C. Giving the client a list of home care assistants to contact is incorrect. While this could be helpful, it is the nurse's role to actively assist in arranging care. Referring the client to a list of names without offering concrete help may leave the client in a challenging situation.

D. Contacting the next of kin to assist the client at home is incorrect. Although contacting a relative may be an option, it may not be viable or practical for the client. Home health care offers a more reliable solution, as family members may not always be available to provide consistent care.

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Correct Answer is C

Explanation

A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.

B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.

C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.

D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.

A. "I will increase my fluid intake to 1,700 milliliters per day." B. "I should do aerobic exercises once per day." C. "I will consume low-protein, low-calorie foods." D. "I should practice pursed-lip breathing exercises."

Correct Answer is D

Explanation

A. "I will increase my fluid intake to 1,700 milliliters per day.": While maintaining hydration is important for people with COPD, 1,700 milliliters may not be sufficient for all individuals. Fluid intake should be tailored to the patient's needs, and the client should be advised to follow specific guidelines from their provider.

B. "I should do aerobic exercises once per day.": This is somewhat correct, as regular exercise is beneficial for people with COPD, but it should be individualized based on the client's current condition and limitations. However, exercise should not be the primary focus of initial teaching for someone newly diagnosed with COPD.

C. "I will consume low-protein, low-calorie foods.": This is incorrect. COPD clients generally need a balanced diet with sufficient protein and calories to support respiratory function and muscle strength. A low-calorie diet may contribute to weight loss and muscle wasting, which can worsen COPD symptoms.

D. "I should practice pursed-lip breathing exercises.": This is correct. Pursed-lip breathing helps to control shortness of breath, improve ventilation, and reduce the work of breathing, which is an important strategy for individuals with COPD to manage their condition.

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A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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