A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?

"I will take my warfarin with a glass of water the night before my surgery."

"I understand what risks I can expect with this surgery."

"I will take time to relax if i get nervous the night before surgery."

"I will have a glass of water the morning of my surgery."

Answer and Explanation

The Correct Answer is A

A. "I will take my warfarin with a glass of water the night before my surgery":

This statement indicates a need for further teaching. Warfarin is an anticoagulant medication, and it should typically be discontinued or adjusted before surgery to reduce the risk of excessive bleeding. Taking it the night before surgery could increase the risk of bleeding during the procedure.

B. "I understand what risks I can expect with this surgery":

This statement suggests that the client has received information about the risks associated with the surgery, which is an essential component of preoperative education. There is no indication for further teaching based on this statement.

C. "I will take time to relax if I get nervous the night before surgery":

This statement demonstrates the client's awareness of the importance of managing stress and anxiety before surgery, which is a positive coping strategy. There is no need for further teaching based on this statement.

D. "I will have a glass of water the morning of my surgery":

This statement is generally acceptable. Clear fluids may be allowed up to a certain time before surgery, depending on the facility's protocol. However, specific instructions regarding fasting before surgery should be clarified with the healthcare provider or surgical team to ensure adherence to preoperative guidelines.

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Correct Answer is C

Explanation

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (PaCO2) by the lungs, leading to an increase in the partial pressure of carbon dioxide (hypercapnia) and a decrease in pH.

In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis. The pH is below the normal range, suggesting acidemia.

The other ABG values (PaO2, oxygen saturation, and bicarbonate) are within or close to normal limits, which do not support the diagnosis of metabolic acidosis, respiratory alkalosis, or metabolic alkalosis.

A. Lean back in the chair. B. Use intermittent eye contact. C. Have a pen and paper. D. Sit side-by-side with the client.

Correct Answer is B

Explanation

(A) Lean back in the chair: Leaning back in the chair can be perceived as a relaxed posture, but it might also convey disinterest or detachment in the conversation. Active listening involves being engaged and showing interest in what the client is saying.

(B) Use intermittent eye contact: This is the most appropriate answer. Maintaining eye contact is an important part of active listening as it shows that the nurse is focused and interested in what the client is saying. However, constant eye contact can be intimidating or uncomfortable for some clients, so intermittent eye contact is often more appropriate.

(c) Have a pen and paper: Having a pen and paper can be useful for note-taking, but it is not a direct action of active listening. It’s important to maintain focus on the client during the conversation, and excessive note-taking can be distracting.

(D) Sit side-by-side with the client: While sitting side-by-side with the client can create a more relaxed and equal atmosphere, it is not a direct action of active listening. The nurse should face the client and maintain appropriate eye contact to show engagement and interest.

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A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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