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 C
Explanation
A. Encouraging the parents to suppress their grief can be detrimental to their emotional well- being and may inhibit healthy grieving processes.
B. Avoiding discussing the funeral when the child is around may create confusion and anxiety for the child, who may sense that something significant is happening but is excluded from the discussion.
C. Including the child in the funeral service before visitors arrive allows the child to be part of the grieving process and provides an opportunity for closure and understanding of the sibling's death in a supportive environment.
D. While it is important for parents to understand how school-age children perceive death, this statement does not offer guidance on how to support the child during the grieving process.
Correct Answer is D
Explanation
Choice A Rationale: The recommended hepatitis vaccine series does not consist of four vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends a 3-dose series for most individuals, which includes doses at birth, 1-2 months, and 6-18 months.
Choice B Rationale: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through exposure to infectious blood, semen, and other body fluids. Transmission can occur through direct contact with blood or body fluids of an infected person, unprotected sex, sharing needles, or from mother to child at birth.
Choice C Rationale: While chronic hepatitis C has been associated with an increased risk of developing renal cell carcinoma, the evidence linking chronic hepatitis B with renal cell cancer is less clear. Some studies suggest a potential association, but it is not established as a common complication.
Choice D Rationale: Individuals with a history of hepatitis B or C are generally ineligible to donate blood. This is due to the risk of bloodborne transmission of these viruses. Even if the individual has recovered or been cured of hepatitis C, they are still barred from donating blood or plasma.
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