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 B

Explanation

(A) Document the rhythm as normal: Asystole is a serious condition characterized by a flatline ECG, indicating no electrical activity in the heart. It is not a normal rhythm and requires immediate intervention.

(B) Start cardiopulmonary resuscitation (CPR): This is the most appropriate initial action. Asystole is a life-threatening condition that requires immediate intervention. The first step should be to start CPR and call for help.

(c) Prepare the patient for cardioversion: Cardioversion is typically used to treat conditions where the heart is beating irregularly (arrhythmias), but not when there is no electrical activity at all (asystole).

(D) Prepare to administer atropine: Atropine is sometimes used in the treatment of bradycardia (slow heart rate), not asystole. In the case of asystole, epinephrine is more commonly administered during resuscitation efforts.

A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

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.

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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

The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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