A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

"I should breathe normally while I am performing this relaxation technique.".

"I should imagine myself in a peaceful, garden-like setting as I begin.".

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them.".

"I'll use a series of stretches when I practice this technique.".

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”

Choice A rationale: While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.

Choice B rationale: Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.

Choice C rationale: This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.

Choice D rationale: Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.

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Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

A. Administering a rectal suppository for a client who has postoperative constipation. B. Instructing a postoperative client to use an incentive spirometer. C. Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis. D. Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge.

Correct Answer is D

Explanation

Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.

Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.

Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.

Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.

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A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is D

Explanation

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