5.4.5: FRAME 5- Take Action
- Page ID
- 90263
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CORRECT Answer
Question Type: Multiple Choice
Scoring: 0/1
NCSBN Item Type and Scoring: https://www.ncsbn.org/public-files/p...main_stage.pdf
The nurse enters the client’s room to see Jacklyn is sitting in the chair, eating breakfast. The nurse sees Jacklyn’s nasal canula laying on the bed next to her. The nurse asks Jacklyn how she is feeling this morning, and she states, “I’m feeling better each day, it is just so hard to eat with that thing stuck up your nose, so I took it off…I hope that is okay.”
What action will nurse take next?
- Put the nasal canula back on the client
- Tell Jacklyn if she becomes short of breath to put it back on
- Check Sp02
- Educate Jacklyn on the importance of keeping things on until the nurse says it is okay to take off
RATIONALE
The client’s chart, including nursing notes, lab values, and vital signs all indicate improvement in Jacklyn’s oxygenation and breathing status. Therefore, it would be appropriate for the nurse’s next action to see what the client’s pulse oximetry is to assess the client’s ability to oxygenate without supplemental oxygen. If the SpO2 is adequate and the client is not showing signs of distress, it would be appropriate to keep the oxygen off the client. Additionally, this forward progress will help support Jacklyn’s mental and emotional states as it will bring positive thoughts forward as she is not reliant on medical therapies as much.
FOCUSED GUIDE
Cardiac rehab is a specific type of therapy focused on clients who have had a recent heart attack, heart conditions such as CAD or heart failure, peripheral artery disease, or heart procedures/surgeries. Additionally, there are many other types of therapies to promote better health outcomes for clients after major surgery. Many of these therapies include a multidisciplinary team that may include providers, nurses, exercise specialists, dieticians, nutritionists, and many others. Rehabilitation measures focus on holistic approaches to promoting independence and healthy living. This includes physical, mental, and emotional support for clients as they recover. It is evident Jacklyn is already seeing a positive impact from cardiac rehab, especially from a mental and emotional supportive aspect. Developing a sense of community for clients to ensure they are not alone can provide significant positive and forward progression with their recovery.
Additionally, transportation is an important SDOH in rural communities. Jacklyn lives in a rural community and relies on her son for transportation. The availability of reliable transportation impacts an individual’s ability to access appropriate and well-coordinated healthcare, purchase nutritious food, and otherwise care for themselves. Rural populations have a greater need for transportation services to maintain their health and well-being. Populations most at risk include older adults, people with disabilities, low-income individuals and families, veterans, and people with special healthcare needs who require additional assistance to access health care. Communities that provide transportation services to support access to rural healthcare benefit healthcare providers by decreasing inappropriate use of EMS services, improve utilization of healthcare services, decrease no-show rates, and increase access to healthsupporting services. Transportation as a community-based service can allow the elderly and people with disabilities to live successfully in a community rather than entering a long-term care facility or leaving the community (Rural Health Information Hub, 2022).