Exhibits
Click to highlight the findings that indicate the client is stable for discharge.
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.
She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment
Neurological Alert and oriented times 4. Cardiovascular WNL
Respiratory WNL
Gastrointestinal/Genitourinary Voided twice throughout night
ambulated 100 yards (91 meters) last night and 200 yards
pain rating of 2
tolerated fluids
Alert and oriented times 4
Voided twice
Respiratory WNL
Cardiovascular WNL
no nausea or vomiting
The Correct Answer is ["A","B","C","D","E"]
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment
Neurological Alert and oriented times 4.
Cardiovascular WNL
Respiratory WNL
Gastrointestinal/Genitourinary Voided twice throughout night
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Attempting to distract the client with general conversation can help redirect the client's focus away from the discomfort and anxiety associated with the procedure. It can help alleviate anxiety and make the experience more tolerable for the client.
B. Explaining the procedure in detail while removing the staples may increase the client's anxiety and discomfort. While education about the procedure is important, it may not be the most
effective intervention in this situation.
C. Encouraging the client to continue to verbalize the anxiety acknowledges the client's feelings but may not effectively address the anxiety or alleviate discomfort during the procedure.
D. Reassuring the client that this is a simple nursing procedure may not be sufficient to alleviate the client's anxiety. The client's perception of the procedure as distressing is valid, and additional measures may be needed to help manage the anxiety and discomfort.
Correct Answer is D
Explanation
A. Administering the placebo as prescribed when the client reports pain is ethically questionable.
Placebos are typically used in research or clinical trials and should not be administered without the client's informed consent and understanding.
B. While informing the charge nurse about the prescribed placebo is appropriate, refusing to administer it without further action may not address the ethical concerns surrounding placebo use.
C. Informing the client that the provider prescribed a placebo instead of pain medication is important for transparency and informed consent. However, this should be accompanied by discussing the ethical considerations with the healthcare provider.
D. Discussing ethical concerns about placebo use with the healthcare provider is the most appropriate intervention. This ensures that the nurse advocates for the client's well-being and addresses any potential ethical issues surrounding the use of placebos in pain management.
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