The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?
"Will let the patient keep her nail polish on."
"Should remove her dentures."
"Can give her dentures to her family."
"Need a new set of vital signs before surgery."
The Correct Answer is A
Choice A reason: Nail polish should generally be removed before surgery to allow the pulse oximeter to function properly, but it is not as critical as removing dentures.
Choice B reason: Dentures should be removed before surgery to prevent aspiration and other complications during anesthesia.
Choice C reason: Giving dentures to the family is appropriate after they have been removed, so this does not warrant intervention.
Choice D reason: It is standard procedure to get a new set of vital signs before surgery, so this statement is correct and does not warrant intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.
Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.
Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.
Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.
Correct Answer is B
Explanation
Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.
Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.
Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.
Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.
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