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 B

Explanation

A. Client's healthcare power of attorney: While important, this information may not be
immediately relevant to the client's current condition and the reason for contacting the healthcare provider.
B. Increasing confusion of the client: This information indicates a change in the client's status and is the most pertinent to the client's current condition, warranting immediate attention.
C. Fall at home as reason for admission: While important for background information, the reason for admission is already known, and the focus of the communication should be on the client's current status.
D. Currently prescribed medications: This information is important but may not be the priority when reporting a change in the client's condition.

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client's positive airway pressure device. D. Lift and lock the side rails in place.

Correct Answer is C

Explanation

A. Remove dentures or other oral appliance: While important for airway management, it is not specifically related to the client's condition of sleep apnea.
B. Elevate the head of the bed to a 45-degree angle: This intervention can help reduce the risk of aspiration but is not specific to managing sleep apnea.
C. Apply the client's positive airway pressure device: Clients with obstructive sleep apnea often use positive airway pressure devices to maintain airway patency during sleep, so ensuring its application is crucial.
D. Lift and lock the side rails in place: This intervention is important for client safety but does not directly address the client's sleep apnea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Correct Answer is C

Explanation

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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?

Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.