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","E"]
Explanation
A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.
B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.
C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.
D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.
E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.
Correct Answer is B
Explanation
A. Keeping the television on at night can cause confusion and disrupt sleep patterns, increasing the risk of injury.
B. Assisting the client to the toilet frequently can prevent falls and reduce the risk of incontinence-related injuries.
C. Raising side rails may increase the risk of injury due to falls or entrapment.
D. Placing the bedside table at the foot of the bed may lead to confusion and increase fall risk.
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