A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?

Inform the client that this procedure is the only option they have for treatment.

Reinforce and clarify the information provided by the surgeon with the client.

Terminate the conversation and state. "It's too late to cancel the procedure."

Delay the procedure and enlist additional staff to persuade the client to have the procedure.

Answer and Explanation

The Correct Answer is B

A. It is important to provide the client with all options available, including risks, benefits, and alternatives to the surgery. Telling the client that the procedure is the only option may limit their autonomy and decision-making ability.

B. The nurse should reinforce the information already provided by the surgeon and clarify any questions the client may have. This ensures that the client is fully informed and can make an educated decision about their care. Encouraging open communication helps the client feel more comfortable with their decision.

C. This response disregards the client’s right to make decisions about their own care. The client must be given the opportunity to express concerns and make an informed choice about their treatment.

D. Persuading the client to undergo surgery is not appropriate. The nurse should support the client’s decision-making process, providing clear and accurate information while respecting their autonomy. Coercion is unethical and does not align with patient-centered care.

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Correct Answer is C

Explanation

A. Excessive urinary output: In syndrome of inappropriate antidiuretic hormone (SIADH), there is decreased urinary output, not excessive output. The body retains water due to increased antidiuretic hormone (ADH), leading to fluid retention.

B. Elevated sodium level: Due to excessive water retention and dilution of electrolytes, clients with SIADH typically experience hyponatremia (decreased sodium level), not an elevated sodium level. The retained water dilutes the body's sodium concentration.

C. Bounding peripheral pulses: Bounding peripheral pulses are expected in SIADH due to fluid overload, as the body retains excessive water. This leads to increased blood volume and can cause the peripheral pulses to feel strong or "bounding."

D. Hyperactive deep tendon reflexes: Hyperactive deep tendon reflexes are typically associated with conditions such as hypercalcemia or hyperthyroidism, not SIADH. SIADH is more likely to cause muscle weakness and fatigue due to hyponatremia.

A. Remove weights when pulling the client up in bed. B. Check the rope for fraying every 8 hr. C. Cleanse the pin sites with hydrogen peroxide. D. Inspect the pin sites for infection every 24 hr.

Correct Answer is B

Explanation

A. Remove weights when pulling the client up in bed: Weights should never be removed from skeletal traction unless ordered by a healthcare provider. Removing weights disrupts the traction's purpose and alignment, potentially causing complications.

B. Check the rope for fraying every 8 hr: Checking the rope for fraying every 8 hours is an appropriate and safe practice in skeletal traction. Ensuring that the rope is intact and functioning properly is essential for maintaining the stability and effectiveness of the traction.

C. Cleanse the pin sites with hydrogen peroxide: Hydrogen peroxide can be too harsh for cleaning pin sites, as it may damage tissue and delay healing. A sterile saline solution is usually preferred for cleaning pin sites unless otherwise prescribed.

D. Inspect the pin sites for infection every 24 hr: Pin site inspections should be done at least once per shift, not just every 24 hours, to promptly detect any signs of infection, as early intervention is key.

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A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who has skeletal traction for a fracture of the lower extremity. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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