A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?

"I will make a note in your medical record that you don't understand the surgery."

"I will tell your provider that you have questions about the surgery."

"Would you like to hear about some other possible treatment options?"

"Would you like me to tell you more about the procedure?"

Answer and Explanation

The Correct Answer is B

A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.

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Correct Answer is ["A","C","D","F","G"]

Explanation

A. Administer oxygen at 10 L/min via nonrebreather face mask. The fetal heart rate (FHR) is 168/min with minimal variability, which indicates potential fetal distress or hypoxia. Providing oxygen can improve fetal oxygenation.

B. Request a prescription for hydralazine. Hydralazine is used for severe hypertension in pregnancy (BP ≥160/110 mm Hg). The client’s BP is 132/84 mm Hg, which does not indicate a need for antihypertensive medication at this time.

C. Initiate a bolus of IV fluid. IV fluid bolus can improve placental perfusion, increase maternal blood pressure (if hypotension is a concern), and correct fetal heart rate abnormalities. This is especially important with minimal variability.

D. Assist the client to the left lateral position. Repositioning to the left lateral position improves uteroplacental blood flow and may help correct FHR abnormalities.

E. Request a prescription for oxytocin. Oxytocin is used to augment labor. However, the priority here is managing fetal distress, not increasing contractions. Oxytocin may worsen fetal distress, so it is not appropriate at this time.

F. Notify the provider of the client's condition. The combination of tachycardia (FHR 168/min), minimal variability, and meconium-stained fluid indicates possible fetal distress. The provider must be notified immediately to determine further interventions.

G. Prepare to administer an amnioinfusion. Meconium-stained fluid increases the risk of meconium aspiration syndrome. An amnioinfusion (infusion of sterile fluid into the amniotic sac via an intrauterine catheter) can help dilute thick meconium and improve fetal well-being.

A. "Did anything in particular make you feel this way?" B. "Would you tell me more about the changes you see in your body?" C. "Do you ever think about harming yourself?" D. "How long have you had these feelings of uselessness?"

Correct Answer is C

Explanation

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?

Nursing Test Bank

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A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?