Case Study 6 - Mobility|Updated&Verified|100% Solved|Guaranteed Success

The client states that the pain level in his right foot is 8 on a scale of 1 to 10. He says he has been favoring his foot by staying in bed the past week. Client was prescribed morphine IV 0.05 mg/kg/dose now and every 2 hours as needed for moderate to severe pain. Morphine is available in parenteral dose of 2 mg/mL. How much medication should the nurse draw up for administration? (Patient weights 140 lbs on admission). 1.6 mL Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first? A. Ask the client what liquid he would like to drink to swallow the pill. B. Teach the client the side effects of the medication. C. Ask the client if he is aware of any allergies to medications. D. Instruct the client to sit upright to swallow the medication. C. Ask the client if he is aware of any allergies to medications. This action should be taken first since this is the initial dose of a new medication. It is important to verify any allergies. Clients sometimes recall addition allergies after the initial admission history has been taken. When the client's foot pain is controlled which nursing diagnosis should take priority? A. Risk for caregiver role strain. B. Risk for social isolation. C. Impaired physical mobility. D. Imbalanced nutrition: more than body requirements. C. Impaired physical mobility. The client's limited activities support the nursing diagnosis. Improving mobility is a nursing priority to prevent the many potential complications of immobility. Which goal is correct for the client's diagnosis of impaired physical mobility? A. The client will transfer to the chair with assist of one person. B. The nurse will reposition the client every hour while the client is awake. C. The client will sit in the chair for each meal beginning on the day of admission. D. The nurse will assist the client to ambulate in the hall by the second hospital day. C. The client will sit in the chair for each meal beginning on the day of admission. This is a correctly stated goal. The client is always the subject of the goal, and the action is always measurable. This goal includes what the client is to achieve and sets a realistic deadline. Prevention of Venous Thrombosis The client is reluctant to move in the bed or move to the chair. He likes his wife to place a pillow under his knee. The nurse informs the client and his wife that the primary care physician (PCP) has ordered enoxaparin injections and antiembolic stockings. The nurse the performs a physical assessment, which reveals diminished dorsalis pedis pulses bilaterally. Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? (Select all that apply) A. Encourage the client to use the incentive spirometer 10 times am hour while awake. B. Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. C. Instruct the client to wear sequential compression stockings D. Advise the client to try not to move and cause pain in his foot wound. E. Explain that enoxaparin injections will be administered routinely. B. Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. (This action stimulates circulation by contracting calf muscles, which increases the venous return of blood to the heart. This decreases pooling of blood in the legs, which helps prevent venous thrombosis in the legs) C. Instruct the client to wear sequential compression stockings. (Sequential compression devices (SCD's) promote venous blood flow, preventing VTE) E. Explain that enoxaparin injections will be administered routinely. (Enoxaparin is an anticoagulant that is administered to reduce the risk of VTE) The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene? A. Palpating bilateral pedal pulses B. Assessing the capillary refill in the great toe C. Assessing the Homan's sign in bilateral extremities D. Applying light pressure in ankles to determine edema C. Assessing the Homan's sign in bilateral extremities. Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot dislodgement. The client is wearing thigh-high antiembolic hose prescriber by the Healthcare Provider (HCP). The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP? A. Paresthesia B. Decreases hair growth in lower legs C. Negative for pallor D. Unilateral calf edema D. Unilateral calf edema. Edema or swelling of one calf is a possible sign of thrombophlebitis that should be reported to the HCP