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.

Nursing Test Bank

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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. Improve stress management skills. B. Achieve satisfactory pain control. C. Reduce risk for infection. D. Obtain adequate rest and sleep.

Correct Answer is B

Explanation

A. Improving stress management skills might be beneficial for overall well-being, but it's not the primary goal in managing degenerative joint disease (DJD. Stress management could be a
secondary intervention to support pain management, but it's not the primary goal.
B. Achieving satisfactory pain control is crucial because pain management is a primary concern for clients with degenerative joint disease (DJD. It directly addresses the client's comfort and
quality of life.
C. While reducing the risk for infection is important in nursing care, it's not the primary goal specifically related to degenerative joint disease (DJD. Infection prevention measures are
important for overall health but aren't directly addressing the primary concern of pain management.
D. Obtaining adequate rest and sleep is important for overall health, but it's not the primary goal when planning nursing care for a client with degenerative joint disease (DJD. Pain control
typically takes precedence in the care plan because pain can significantly impact rest and sleep.

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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

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

Correct Answer is B

Explanation

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?

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

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?

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 The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? 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 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?