A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

"Why have you changed your mind about the surgery?"

"Your provider would not have scheduled the surgery unless you needed it."

"I will call your doctor and have him discuss your surgery with you."

"Bypass surgery must be very frightening for you."

Answer and Explanation

The Correct Answer is D

A. "Why have you changed your mind about the surgery?" Asking "why" may sound accusatory and could cause the client to feel defensive. It's more effective to use therapeutic communication techniques that encourage open expression of feelings.

B. "Your provider would not have scheduled the surgery unless you needed it."This response minimizes the client's concerns and implies that their feelings are not valid, which can hinder communication.

C. "I will call your doctor and have him discuss your surgery with you." While involving the provider is important, this response deflects the client's concerns without first addressing their feelings or providing support.

D. "Bypass surgery must be very frightening for you." This response uses a therapeutic communication technique by acknowledging the client’s emotions and opening the conversation for further exploration of their concerns.

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Correct Answer is B

Explanation

A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. The apical pulse is located at the apex of the heart, not at the carotid artery. This option does not describe the correct location or use of the stethoscope.

B. Count the apical pulsations for a full minute. Counting for a full minute is the correct method for assessing an apical pulse, particularly in clients on cardiovascular medications, to ensure accurate detection of any irregularities.

C. Check the apical pulse with a Doppler device. A Doppler device is typically used to assess peripheral pulses, not the apical pulse. A stethoscope is the appropriate tool for apical pulse assessment.

D. Press the stethoscope firmly against the client's skin. While the stethoscope should be placed firmly enough to hear heart sounds, excessive pressure can distort the sounds and is not necessary.

A. Measure the client's ankle circumference. B. Measure from the client's heel to the gluteal fold. C. Measure from the client's heel to the popliteal space. D. Measure the length of the client's feet.

Correct Answer is C

Explanation

A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.

B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.

C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.

D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.

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A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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