A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?
Provide the client with a walker.
Premedicate the client with the prescribed analgesic.
Obtain the client's vital signs and oximetry prior to ambulation.
Reinforce the client's surgical dressing.
The Correct Answer is C
A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.
B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.
C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.
D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical
incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.
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Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is C
Explanation
A. Tilted head position facilitates drainage into the nasolacrimal duct, not necessarily into the eye.
B. Washing away exudate is not necessary before administering eye drops.
C. Using aseptic technique to drop medication into the conjunctival sac ensures proper delivery of the medication to the eye.
D. Dropping medication onto the cornea can cause discomfort and may not effectively reach the eye.
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