When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

The nurse does not want the client to feel lonely.

The client will be more compliant with medical instructions.

The family will be more willing to listen to instructions.

Illness in one family member can affect the other family members.

Answer and Explanation

The Correct Answer is D

Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

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Correct Answer is B

Explanation

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

A. Client’s wound dressing is dry. B. Client is awake and oriented. C. Client is breathing. D. Client’s foley catheter is draining.

Correct Answer is C

Explanation

The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.

This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.

The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.

Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.

Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.

Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.

Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.

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When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Correct Answer is B

Explanation

A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?

Correct Answer is C

Explanation

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

A health care provider prescribes one ounce of an elixir medication for a client. How many milliliters (mL) of medication should the nurse instruct the client to take during discharge teaching?

Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).

A community health nurse is teaching a group of older adults about risk factors for a hip fracture. What statements indicate a correct understanding of these risk factors? Select all that apply.

Following a uterine biopsy, a client asks a nurse, “Do you think I have cancer?” Which response by the nurse would most likely prompt the client to elaborate on their concerns?