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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A Reason: Parent who has cardiovascular disease

Having a parent with cardiovascular disease is considered a non-modifiable risk factor. This means it is related to genetic predisposition and cannot be changed or controlled by the individual. While family history is important in assessing stroke risk, it is not something that can be modified through lifestyle changes or medical interventions.

Choice B Reason: Client’s age

Age is another non-modifiable risk factor for stroke. The risk of stroke increases with age, but it is not something that can be altered. While age is an important consideration in stroke risk assessment, it is not a factor that can be modified to reduce the risk.

Choice C Reason: History of sickle cell disease

Sickle cell disease is a genetic disorder that affects the shape and function of red blood cells. It is a non-modifiable risk factor for stroke because it is inherited and cannot be changed. While managing sickle cell disease can help reduce complications, the condition itself remains a fixed risk factor.

Choice D Reason: Hypertension

Hypertension, or high blood pressure, is a significant modifiable risk factor for stroke. It can be managed and controlled through lifestyle changes such as diet, exercise, and medication. Lowering blood pressure can significantly reduce the risk of stroke, making it a key focus in stroke prevention efforts.

A. Contact B. Protective C. Airborne D. Droplet

Correct Answer is A

Explanation

Choice A Reason:

Contact precautions are recommended for patients with MRSA to prevent the spread of the bacteria. This includes measures such as placing the patient in a single room, using personal protective equipment (PPE) like gowns and gloves, and ensuring proper hand hygiene. These precautions help to minimize the risk of transmission through direct or indirect contact with the patient or their environment.

Choice B Reason:

Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. This is not applicable for MRSA patients, as the goal is to prevent the spread of MRSA to others, not to protect the patient from external infections.

Choice C Reason:

Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis or measles. MRSA is not transmitted through airborne particles, so this type of precaution is not appropriate.

Choice D Reason:

Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. MRSA is primarily spread through direct contact, not through respiratory droplets, making droplet precautions unnecessary.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?

Correct Answer is D

Explanation

A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?

Correct Answer is A

Explanation

A nurse is teaching a client who has constipation. Which of the following statements should the nurse include?

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

A nurse is providing care to a client who has Parkinson’s disease and is having difficulty swallowing. Which of the following departments should the nurse plan to contact for a consultation?

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 education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

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?

A nurse is caring for a client who states their parent died from complications of a GI bleed. Which of the following statements from the nurse will help the client decrease their risk of developing a peptic ulcer?

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)