A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

"It must be difficult facing this type of surgery.”

"Other clients who have had this surgery have done just fine.”

"This facility is known for providing excellent care for people who need this type of surgery.”

"I can request a sleeping pill if you think that will help.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice a. "It must be difficult facing this type of surgery.”

Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.

Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.

Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.

Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible.

Correct Answer is D

Explanation

The correct answer is: d. Remove the staple from the skin after both sides are visible.

Explanation: This statement is correct because the staple should be removed only when both sides are visible, ensuring that it has been fully lifted away from the skin. This helps minimize tissue damage and pain while preventing infection.

Choice A Rationale: Lifting the staple remover when squeezing the handle could potentially disrupt the proper angle required for effective staple removal. Staples are designed to be removed in a specific manner to minimize tissue trauma and discomfort to the patient. If the staple remover is lifted while squeezing the handle, it may cause uneven pressure on the staple legs, leading to improper removal. This could result in tissue damage, increased pain for the patient, and potentially leave parts of the staple embedded in the skin, increasing the risk of infection or delayed healing.

Choice B Rationale: Avoiding completely closing the handle after squeezing may not provide sufficient force to properly remove the staple from the skin. Staples are designed to be squeezed closed completely to ensure that they are securely grasped and removed from the incision site. Failing to fully close the handle after squeezing may result in inadequate removal of the staple, leaving parts of it behind in the skin. This can increase the risk of infection, tissue irritation, and delayed wound healing. Additionally, incomplete closure of the handle may lead to discomfort for the patient as the staple removal process may be prolonged or require additional attempts.

Choice C Rationale: Expecting the staples to bend at each outer side during removal is incorrect. Staples are designed to bend in the middle when properly removed from the skin. If the outer sides of the staple were expected to bend, it may indicate improper technique or the use of a faulty staple remover. Staples are intended to be removed smoothly without excessive bending or twisting to minimize trauma to the surrounding tissue and reduce the risk of complications such as infection or delayed wound healing. Anticipating bending at the outer sides could lead to unnecessary manipulation of the staple and increase the likelihood of tissue damage or incomplete removal.

Choice D (Correct Answer) Rationale: Removing the staple from the skin only after both sides are visible is the appropriate technique to ensure proper removal without causing unnecessary trauma or discomfort to the patient. When both sides of the staple are visible, it indicates that the staple has been adequately lifted away from the skin, reducing the risk of tissue damage or incomplete removal. This technique allows for a smooth and controlled extraction of the staple, minimizing pain and promoting optimal wound healing. By waiting until both sides are visible, the nurse can confirm that the staple has been fully disengaged from the tissue, reducing the likelihood of complications such as infection or skin irritation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?