A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
Encourage the client to avoid wearing shoes at home.
Place a throw rug over electrical cords.
Ensure that area rugs have rubber backs.
Mark the edges of the doorway to the house with tape.
The Correct Answer is C
A. Wearing well-fitted shoes at home helps prevent slips and falls.
B. Placing throw rugs over electrical cords increases the risk of tripping.
C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.
D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Perform chest percussion and vibration. Chest percussion and vibration help loosen and mobilize mucus in the airways, which is essential for clients with productive cough and a history of smoking-related respiratory issues. This intervention facilitates effective expectoration and improves breathing.
B. Place the client in a supine position. Placing the client in a supine position can worsen shortness of breath, especially in individuals with respiratory distress. The client should be positioned upright or in a high-Fowler's position to facilitate lung expansion.
C. Instruct the client to perform diaphragmatic breathing. Diaphragmatic breathing helps improve lung expansion, reduce the work of breathing, and promote relaxation. This technique is particularly useful for clients with an irregular breathing pattern and anxiety.
D. Assess the client's breath sounds. Continuous assessment of breath sounds is critical to monitor the effectiveness of interventions, such as oxygen therapy and nebulization, and to detect any worsening of respiratory status.
E. Restrict the client's fluid intake. Fluid intake should not be restricted unless contraindicated, as hydration helps thin mucus, making it easier to expectorate. This is particularly important for clients with a productive cough.
F. Increase oxygen flow rate to 4 L/min. Increasing the oxygen flow rate beyond 2 L/min requires caution in clients with chronic obstructive pulmonary disease (COPD) or similar conditions, as higher oxygen levels can suppress their respiratory drive. Oxygen therapy should be titrated carefully based on the provider's prescription and monitoring of oxygen saturation.
Correct Answer is B
Explanation
A. Belief in being reunited with the child is a common and healthy coping mechanism.
B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.
C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.
D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.
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