A nurse is caring for a client who is scheduled to undergo abdominal surgery and tells the nurse that he is very anxious about the operation. Which of the following actions should the nurse take?

Distract the client by giving him reading material.

Suggest that he take a walk around the unit.

Ask him to describe his concerns.

Refer him to the spiritual care team.

Answer and Explanation

The Correct Answer is C

A. Distract the client by giving him reading material. Distraction may not address the underlying anxiety and could delay processing the client's concerns about the surgery.

B. Suggest that he take a walk around the unit. While walking can help with anxiety in some patients, it does not directly address the client's expressed concern about the surgery itself.

C. Ask him to describe his concerns. The nurse should acknowledge the patient's feelings by encouraging them to express their concerns. This helps reduce anxiety and provides valuable information for further support.

D. Refer him to the spiritual care team. While spiritual care may be beneficial later, it’s essential to first address the patient’s immediate concerns before referring them to other services.

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Correct Answer is ["C","E"]

Explanation

A. Dry crust on the incision line.
Dry crust on the incision line could indicate that the wound is healing well, but it is not typically a sign of infection. Infection is more commonly associated with redness, warmth, and drainage. A dry crust does not automatically suggest infection.

B. Increased urine output.
Increased urine output is generally a sign of good hydration or adequate kidney function, not an indication of infection. Infection would more likely present with a fever or abnormal wound appearance, not increased urine output.

C. Decreased level of consciousness.
A decreased level of consciousness can be a sign of sepsis, an infection that has spread throughout the body. This is a serious indicator of possible infection, especially if it is sudden or unexplained in the postoperative period.

D. Adventitious breath sounds.
Adventitious breath sounds could be a sign of a respiratory infection or complications such as pneumonia, but they are not necessarily linked to infection at the surgical site. If the sounds are related to infection, this could be a sign of a lower respiratory tract infection.

E. Oral temperature of 38.3° C (101° F).
An oral temperature of 38.3° C (101° F) is a fever, which is a classic sign of infection. Fever is a common early sign of infection in the postoperative period and should be promptly addressed to rule out surgical site infection or other complications.

A. Ill and the patient has depressed reflexes. B. IV and the patient will not depend on the anesthesia machine of oxygenations. C. Il and the surgical environment should be kept quiet. D. and the patient's hearing is amplified.

Correct Answer is C

Explanation

A. Stage III and the patient has depressed reflexes. Stage III of anesthesia is the surgical stage, where the patient is under deep anesthesia, and reflexes are typically depressed. However, tensed muscles and irregular respirations may indicate that the patient is still in an earlier stage of anesthesia (stage II).

B. Stage IV and the patient will not depend on the anesthesia machine for oxygenation. Stage IV is the deepest level of anesthesia, where respiratory and cardiovascular functions are severely depressed. It does not match the description of tensed muscles and irregular respirations, which are more characteristic of an earlier stage (stage II).

C. Stage II and the surgical environment should be kept quiet. Stage II of anesthesia is the excitement stage, where patients may exhibit tensed muscles, irregular respirations, and uncoordinated movements. The surgical environment should be kept quiet to minimize stimuli that could cause agitation or further excitement in this stage.

D. Stage I and the patient's hearing is amplified. Stage I is the stage of anesthesia where the patient is still conscious and responsive to stimuli. The description of tensed muscles and irregular respirations does not match this stage. Additionally, the patient’s hearing would not be amplified in stage I, but rather in stage II or as they begin to emerge from anesthesia.

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A nurse is caring for a client who is scheduled to undergo abdominal surgery and tells the nurse that he is very anxious about the operation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","E"]

Explanation

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Correct Answer is C

Explanation

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