The nurse creates and implements a client's plan of care. Which client outcomes best demonstrate use of evidence-based practice in planning care for the older client? Select all that apply.
1. The client is placed in physical restraints and does not experience a fall.
2. The nurse reports to the next shift nurse that the malnourished client enjoys milkshakes.
3. The client who is at risk of deep vein thrombosis is assisted to walk three times daily.
4. The nurse requests a laxative and administers it while the client is on a narcotic.
5. The nurse allows the client with pneumonia to rest in bed throughout the shift.
2. The nurse reports to the next shift nurse that the malnourished client enjoys milkshakes.
3. The client who is at risk of deep vein thrombosis is assisted to walk three times daily.
4. The nurse requests a laxative and administers it while the client is on a narcotic.
Explanation: 1. It is a positive outcome that the nurse prevented a fall, but physical and chemical restraints are used cautiously, if at all, and are not considered an acceptable fall prevention technique in the older client.
2. The nurse has evidence that this practice works well to encourage the client to take in more nutrients and calories, improving the client's health and treating the client's lack of nourishment. Though not published research, evidence of this kind is used based on trial and error to improve client outcomes.
3. Evidence states that the client at risk for DVT needs to ambulate when possible to prevent clots from forming, with or without compression socks. If ambulation is not realistic, a sequential compression device is used.
4. The nurse uses established evidence and information about narcotics to prevent the problem of constipation in the client. Constipation is the only narcotic side effect clients do not become tolerant to and older clients are at higher risk of constipation.
5. Clients with pneumonia do need rest but also need to be turned, helped to sit up in the chair, and assisted to walk if able. Resting in the bed all day is not the best intervention for the client.
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