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 A
Explanation
Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.
Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.
Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.
Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.
Correct Answer is A
Explanation
Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.
Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.
Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.
Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.
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