A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

“You will not be able to eat breakfast until after you are washed.”.

“Please tell me what is worrying you at this time.”.

“I am going to wash you now and then you will take your medications.”.

“Why are you crying again? We haven’t touched you yet.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

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Correct Answer is D

Explanation

Choice A rationale
Cherry jello is not a part of a full-liquid diet. While it is soft and easy to swallow, it does not provide the necessary nutrients that a patient recovering from surgery for laryngeal cancer would need.
Choice B rationale
Clear broth soup is part of a clear liquid diet, not a full liquid diet. A full liquid diet includes foods that are liquid at room temperature or melt at body temperature.
Choice C rationale
Chicken noodle soup is not suitable for a full-liquid diet. The noodles and chicken pieces could pose a swallowing risk for a patient recovering from surgery for laryngeal cancer.
Choice D rationale
Cream of potato soup is a suitable choice for a full-liquid diet. It is smooth and easy to swallow, and it provides necessary nutrients.

A. Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises. B. Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage. C. Potential Condition: Pulmonary edema. D. Potential Condition: Pneumonia.

Correct Answer is B

Explanation

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

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A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client after surgery for laryngeal cancer about a full liquid diet. What selection made by a client indicates to a nurse that the teaching was effective?

Correct Answer is D

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

Explanation

A patient diagnosed with lung carcinoma is scheduled for a left pneumonectomy. Which nursing intervention should be prioritized in the immediate postoperative period?

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A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

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A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee. The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?

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