While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?

Attempt to distract the client with general conversation.

Explain the procedure in detail while removing the staples.

Encourage the client to continue to verbalize the anxiety.

Reassure the client that this is a simple nursing procedure.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

A. Weigh every morning: Daily weighing helps monitor for fluid retention, which is important in managing heart failure. Sudden weight gain can indicate fluid accumulation and worsening heart failure symptoms, prompting the need for medical attention.
B. Limit fluid intake to 1,500 ml daily: While fluid restriction may be necessary for some
individuals with heart failure, the specific amount varies based on individual circumstances and should be determined by the healthcare provider. A blanket recommendation of 1,500 ml may not be appropriate for all patients.
C. Eat a high protein diet: While a balanced diet is important for overall health, there is no specific evidence to suggest that a high protein diet is essential for heart failure management. Dietary recommendations should be tailored to the individual's needs and comorbidities.
D. Perform range of motion exercises: While exercise is important for overall health, including for individuals with heart failure, range of motion exercises may not be the priority instruction for discharge teaching. Exercise recommendations should be individualized and may include aerobic and resistance training based on the client's condition and functional status.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions. B. Assist the client to recall everyone possibly exposed since onset of symptoms. C. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is A

Explanation

A. Moving the client to a private room, keeping the door closed, and initiating droplet
precautions are important to prevent potential transmission of COVID-19, especially considering the client's symptoms and recent loss of taste and smell, which are associated with COVID-19.
B. Assisting the client to recall everyone possibly exposed since onset of symptoms is relevant for contact tracing but does not address immediate infection control measures for the suspected case.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a correct laboratory procedure but does not address immediate infection control measures for the
suspected case.
D. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for preventing transmission, but in this scenario, immediate isolation
precautions are necessary until a COVID-19 diagnosis is confirmed or ruled out.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is A

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Exhibits Review History and Physical, and laboratory results. Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

A client arrives for an annual physical exam and reports having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?