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 D

Explanation

A. While fluid restriction may be necessary for some clients with heart failure, a general fluid
intake limit of 1,500 mL daily may not be appropriate for all clients. Fluid restriction should be individualized based on the client's clinical status and recommended by the healthcare provider.
B. While a balanced diet, including adequate protein intake, is important for overall health, there is no specific evidence to suggest that a high protein diet is necessary for clients with heart
failure. Dietary recommendations should be individualized based on the client's nutritional needs and medical condition.
C. Range of motion exercises may be beneficial for maintaining joint mobility, but they are not specifically related to managing heart failure symptoms or preventing exacerbations.
D. Weighing every morning is an important self-monitoring strategy for clients with heart failure to assess for fluid retention. Sudden weight gain may indicate fluid accumulation, which can be an early sign of worsening heart failure. Daily weight monitoring allows for early intervention and adjustment of treatment as needed.

A. Teach a family member to administer eye drops. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Teaching a family member to administer eye drops may be appropriate for some clients undergoing eye surgery, but it is not specifically indicated for retinal detachment repair.
B. Encouraging deep breathing and coughing exercises is important for preventing respiratory complications but is not directly related to postoperative care for retinal detachment repair.
C. Providing an eye shield to be worn while sleeping is important to protect the eye and prevent inadvertent trauma during the vulnerable postoperative period. It helps promote healing and
prevents further injury to the eye.
D. Obtaining vital signs every 2 hours during hospitalization is a general nursing intervention but is not specific to the postoperative care of a client undergoing retinal detachment repair.

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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 D

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

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 who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?