Level: Advanced
Difficulty: Hard
Subtopic: Sleep and rest
NCLEX: A 55-year-old client after abdominal surgery is being evaluated for nursing care related to sleep and rest. Asses…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 55-year-old client after abdominal surgery is being evaluated for nursing care related to sleep and rest. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.