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.
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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Related Questions
Correct Answer is D
Explanation
A. Verifying the amount of TPN solution the client is receiving every 4 hours is incorrect. While monitoring the TPN infusion rate is important, the rate and amount are typically verified at the start of the infusion and with each new bag change, not every 4 hours.
B. Placing the client in Sims' position for catheter insertion is incorrect. The preferred position for central venous catheter insertion is Trendelenburg or supine with a slight head turn, which helps dilate the veins and reduce the risk of air embolism.
C. Using clean technique when changing the catheter dressing is incorrect. Central venous catheter care requires sterile technique to prevent infections, including catheter-related bloodstream infections (CRBSIs).
D. Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.
Correct Answer is B
Explanation
A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.
B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.
C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.
D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.
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