A client is being discharged home after a routine hip replacement surgery. The
nurse is instructing the client on how to prevent postoperative
... [Show More] complications.
What statements by the client would indicate the need for further teaching?
Select all that apply.
A. “Limiting fiber is necessary to avoid diarrhea.” Correct
B. “I should empty my bladder when I feel the urge.”
C. “Avoiding pain medication will prevent constipation.” Correct
D. “I should drink plenty of liquids like iced tea or coffee.” Correct
E. “I should continue with my physical therapy and walking.”
Rationale: Constipation is common after surgery due to pain medication,
decreased movement, and anesthesia. Fiber intake should be encouraged as it
promotes the prevention of stool retention. Although pain medication can cause
constipation, it should not be avoided in the post-operative period. Drinking
plenty of fluids is encouraged for both bowel and bladder maintenance, but the
client should choose non-caffeinated options. Physical therapy, walking, and
exercise will help prevent constipation. Emptying the bladder when the urge is
present can help prevent urinary tract infections.
Test taking strategy: Note the strategic words need for further teaching. These
words indicate a negative event query and the need to select the incorrect client
statements. Think about the measures needed for bowel and bladder control to
answer correctly. Review: bowel and bladder maintenance.
Level of Cognitive Ability: Evaluating
Client Need: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Perioperative Care
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health Promotion, Teaching and Learning/Patient Education
References: Giddens, J. (2013). Concepts for nursing practice. (p. 143). St.
Louis, MO: Mosby.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th
ed., pp. 969, 1089-1090). St. Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
2.ID: 9477039828
The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The
client speaks limited English. What should the nurse do to ensure the client and
family receives the most accurate information? Select all that apply.
A. Provide culturally sensitive education. Correct
B. Encourage family members to obtain a tuberculosis skin test.
Correct
C. Provide written instructions in English for the client to reference.
D. Encourage the client and family to wash all dishes by hand to
prevent the spread of infection. Incorrect
E. Urge all family and close contact community members to seek and
complete treatment to enhance compliance. Correct
Rationale: As always, the nurse must provide culturally sensitive education.
Because tuberculosis is highly contagious, all family members and close
community members should have a tuberculosis skin test, seek treatment, and
remain compliant. A full course of 6-9 months of treatment is needed to prevent
re-infection. Instructions written in English are not helpful for the client with
limited English skills. Washing dishes by hand is not the best way to prevent
infection; rather a dishwasher should be used if available.
Test Taking Strategy: Focus on the strategic word most to select correct
options that relate to appropriate teaching for both the client and family
members. Also, focusing on the data in the question will assist in answering.
Review: Tuberculosis
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Implementation
Content Area: Fundamentals of Care: Infection Control
Priority Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
References: Giger, J. (2013). Transcultural nursing assessment & intervention.
(6th
ed. p. 445, 455). St. Louis: Mosby.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 533). St.
Louis: Mosby.
Awarded 1.0 points out of 3.0 possible points.
3.ID: 9477038294
A client with anxiety has just been seen by the hea [Show Less]