When the practical nurse (PN) atempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!"
Which response is best for the PN to make?
A. "You must ambulate to avoid complications which could cause more discomfort than ambulating."
B. "I know you feel angry about the pain of ambulation, but this is a necessary part of getting well."
C. "Your healthcare provider has left specific instructions to ambulate on the first postoperative day."
D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."
The Correct Answer is D
An 18-year-old client with a mild mental disability is a client who has a lower than average intellectual functioning and some limitations in adaptive skills, such as communication, socialization, and self-care. A mild mental disability may affect the client's ability to understand, cope, or cooperate with medical interventions, such as ambulation after surgery.
Ambulation is the act of walking or moving around. It is an important part of postoperative care, as it helps to prevent complications such as deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis, constipation, and pressure ulcers. Ambulation also promotes circulation, wound healing, and muscle strength.
When the practical nurse (PN) atempts to assist the client to ambulate on the first postoperative day after an appendectomy, the client becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" This may indicate that the client is experiencing pain, fear, anxiety, or frustration due to the surgery and the recovery process .
The best response for the PN to make is to acknowledge the client's feelings, provide reassurance and support, and set a clear and realistic goal for ambulation. This will help to establish rapport, reduce resistance, and motivate the client to participate in the care plan.
Therefore, option D is the correct answer, as it shows empathy and respect for the client's feelings, while also informing the client of the expectation and time frame for ambulation. Option D also allows the client some time to prepare mentally and physically for the activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: Assign the remainder of medication administration to another PN who is performing treatments.
Choice A rationale: Denying the medication aide's request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide's request and find an appropriate solution that ensures patient safety and well-being.
Choice B rationale: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.
Choice C rationale: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse's responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.
Choice D rationale: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.
Correct Answer is D
Explanation
Choice A rationale:
Tetracycline antibiotics can form insoluble complexes with calcium, reducing their absorption when taken together. Therefore, advising the client to continue taking calcium supplements with food while on tetracycline therapy is not recommended as it may decrease the effectiveness of the antibiotic.
Choice B rationale:
The nurse should advise the client to avoid taking calcium supplements while on tetracycline therapy. Calcium-containing products (such as supplements, dairy products, and antacids) should be taken at least 2 hours before or after tetracycline administration to minimize the interference with drug absorption.
Choice C rationale:
Taking calcium supplements with tetracycline, even with plenty of water, can still lead to reduced drug absorption due to the formation of insoluble complexes. Therefore, this advice is not appropriate.
Choice D rationale:
The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.
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