A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states. "I cannot do this. I do not want this surgery." Which of the following actions should the nurse take?

Tell the client about the benefits of the surgery.

Inform the client that it is too late to stop the surgery.

Let the client know that their surgeon will be notified of their decision.

Reassure the client that it is expected to be nervous before surgery.

Answer and Explanation

The Correct Answer is C

A.   While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.

B.   It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C.   The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D.   While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.

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Correct Answer is D,E,C,B,A

Explanation

A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.

E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.

A. Use sterile gloves to obtain the sputum specimen. B. Place the sputum specimen in a clean container. C. Collect the sputum specimen in the morning. D. Obtain the sputum specimen after the client uses mouthwash.

Correct Answer is C

Explanation

A. Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.

B. Sputum specimens should be collected in a sterile container to prevent contamination.
C. Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D. Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.

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A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states. "I cannot do this. I do not want this surgery." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,E,C,B,A

Explanation

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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