A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.
The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.
Which of the following statements is the best response from the nurse?
“This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”.
“The most important thing is that now you are here, and it is going to get taken care of.”.
“I will be happy to go and get you some reading materials about this procedure to explain it further.”.
“It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.
The Correct Answer is A
Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.
Correct Answer is ["15"]
Explanation
Step 1 is to determine the amount of clindamycin palmitate in each mL of the oral suspension. This is done by dividing the total amount of clindamycin palmitate in 5 mL by 5. So, 75 mg ÷ 5 mL = 15 mg/mL.
Step 2 is to calculate the volume of oral suspension needed to deliver 225 mg of clindamycin palmitate. This is done by dividing the desired dose by the amount of clindamycin palmitate per mL. So, 225 mg ÷ 15 mg/mL = 15 mL.
Therefore, the nurse should administer 15 mL of clindamycin palmitate oral suspension.
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