A preoperative nurse is caring for a client who is being prepped for emergency surgery related 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?

The most important thing is that now you are here, and it is going to get taken care of.

This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.

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.

Answer and Explanation

The Correct Answer is B

Choice A Reason: The most important thing is that now you are here, and it is going to get taken care of

While this statement is reassuring, it does not provide the client with the specific information they are seeking about adhesions. Clients often feel more at ease when they understand the cause of their condition. Providing clear and accurate information helps reduce anxiety and empowers the client to be more involved in their care.

Choice B Reason: This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine

This statement is the best response because it directly addresses the client’s question about adhesions. Adhesions are bands of scar tissue that can form after abdominal surgery, causing organs or tissues to stick together. These adhesions can constrict the intestines, leading to a blockage. Providing this explanation helps the client understand the cause of their condition and the reason for the surgery.

Choice C Reason: I will be happy to go and get you some reading materials about this procedure to explain it further

Offering reading materials can be helpful, but it does not immediately address the client’s anxiety or their specific question about adhesions. While additional information can be beneficial, the nurse should first provide a clear and direct explanation to help the client understand their condition.

Choice D Reason: It’s okay. It happens all the time and I’ve seen a lot of clients with this issue

This statement may come across as dismissive and does not provide the client with the information they need. While it is important to reassure the client, it is equally important to provide specific information about their condition. Understanding the cause of their symptoms can help reduce anxiety and improve the client’s overall experience.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A Reason:

Removing the protective gown before removing gloves is incorrect. The correct procedure is to remove gloves first, followed by the gown, to prevent contamination from the gown to the hands.

Choice B Reason:

Using an electronic thermometer is not recommended for clients with Clostridium difficile. Disposable thermometers or dedicated equipment should be used to prevent cross-contamination.

Choice C Reason:

This is the correct answer. The protective gown should be removed before leaving the client’s room to prevent the spread of Clostridium difficile spores to other areas of the healthcare facility. Proper removal and disposal of PPE are crucial in infection control.

Choice D Reason:

Shaking bed linens is incorrect as it can aerosolize Clostridium difficile spores, increasing the risk of spreading the infection. Linens should be carefully handled and placed in a linen bag without shaking.

A. “There is no causal link between lying down after eating and increased onset of GERD.” B. “It is okay to take aspirin with GERD.” C. “You should avoid or cut down on alcohol and caffeine which can aggravate GERD.” D. “You should avoid possible mercury-containing foods such as some seafood because of their risk to GERD.”

Correct Answer is C

Explanation

Choice A Reason:

There is a causal link between lying down after eating and the increased onset of GERD. Lying down can cause stomach acid to flow back into the esophagus, exacerbating GERD symptoms.

Choice B Reason:

Taking aspirin with GERD is not recommended. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the stomach lining and worsen GERD symptoms.

Choice C Reason:

This is the correct answer. Alcohol and caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus and aggravate GERD symptoms.

Choice D Reason:

There is no evidence to suggest that mercury-containing foods, such as some seafood, are linked to GERD. The primary dietary concerns for GERD involve foods and beverages that can relax the lower esophageal sphincter or increase stomach acid production.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is educating a client about the risk factors for GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include?

Correct Answer is C

Explanation

An infection control nurse is teaching a class about the transmission of infectious agents. The nurse should include that which of the following diseases is transmitted via airborne transmission? (Select All that Apply.)

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

A nurse is teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?

A nurse is providing teaching to a client who has long-term symptoms of GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include in the educational materials?

An older adult client returned to the nursing home after a lower limb amputation. The client is scheduled for a prosthesis fitting and states, “I am too old to learn how to manage this.” Which of the following responses from the nurse is appropriate?

A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following information should the nurse include in the teaching?

A nurse is providing teaching to a client who has a new diagnosis of Crohn’s disease. Which of the following statements by the nurse provides the most simplistic and non-medical description of the disorder?

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client’s discomfort?