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. Aspiration: While aspiration precautions may be necessary in certain situations, elevated parathyroid hormone levels are not typically associated with an increased risk of aspiration.
B. Falls: Elevated parathyroid hormone levels can lead to hypercalcemia, which may cause weakness, confusion, and increased risk of falls due to muscle weakness and altered mental status.
C. Suicide: While mental health assessment and intervention may be important for overall patient care, elevated parathyroid hormone levels do not directly increase the risk of suicide.
D. Hypothermia: Elevated parathyroid hormone levels are not typically associated with an increased risk of hypothermia. Hypercalcemia may lead to dehydration and electrolyte
imbalances, but hypothermia is not a common complication.

A. Give a bolus of 1,000 mL 0.9% sodium chloride B. Repeat blood gas in 1 hour C. Place the client in a prone position D. Perform endotracheal suctioning E. Chest x-ray now F. Administer inhaled corticosteroid

Correct Answer is ["B","C","D"]

Explanation

A. Giving a bolus of 1,000 mL 0.9% sodium chloride is typically used to treat hypovolemia or electrolyte imbalances, which are not indicated by the patient's current lab values or clinical
situation.
B. Repeating the blood gas in 1 hour is a reasonable order as it would provide information on whether the patient's respiratory status is improving following interventions for ventilator-associated pneumonia.
C. Placing the client in a prone position can improve oxygenation in patients with respiratory distress by redistributing lung perfusion, making it a suitable intervention for this patient with diminished breath sounds and crackles.
D. Performing endotracheal suctioning would help clear secretions, which may be contributing to the patient's diminished breath sounds and crackles, and is consistent with the care for a patient with pneumonia.
E. A chest x-ray now would typically be ordered if there was a suspicion of a new onset condition such as a pneumothorax or pleural effusion, which is not indicated by the patient's current presentation.
F. Administering an inhaled corticosteroid is generally used for long-term management of chronic respiratory conditions and is not typically used for acute management of ventilator-associated pneumonia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

Correct Answer is ["B","C","D"]

Explanation

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

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?

A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Exhibits What should the nurse include in post discharge care education? Select all that apply.

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse 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?

The nurse notes that a client is receiving a heparin infusion labeled, Heparin Sodium 25,000 Units in 5% Dextrose Injection, 500 mL at a rate of 50 mL/hour. What dose of heparin is the client receiving per hour? (Enter the numerical value only.)

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?