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Which client statements require follow-up teaching by the nurse? Select all that apply.

“This diagnosis means that I am crazy.”.

“Many people have the same response to a stressful situation as I am having right now.”.

“I will probably need to be on medication for the rest of my life.”.

“I can use holistic approaches like meditation to help my symptoms.”.

“I am at high risk for post-traumatic stress disorder because I have acute stress disorder.”.

“I can learn to manage my thoughts better through therapy.”.

Answer and Explanation

Correct Answer : A,C

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

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Correct Answer is A

Explanation

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

A. Prompt the nurse to apply povidone to the site. B. Direct the nurse to attach the luer-lock tip to the irrigation port. C. Send an unlicensed assistive personnel to gather equipment. D. Instruct the nurse to use water with 5% dextrose (D5W).

Correct Answer is B

Explanation

Choice A rationale

Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.

Choice B rationale

Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.

Choice C rationale

Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.

Choice D rationale

Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.

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Which client statements require follow-up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

Correct Answer is A

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter.The new nurse has a luer-lock tipped syringe.What action should the charge nurse take?

Correct Answer is B

Explanation

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity.Which test should the nurse schedule the client for evaluation of the symptoms?

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?