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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Encouraging the use of ice on the areola is not appropriate for addressing inverted nipples. Ice may cause discomfort and vasoconstriction, making latching more difficult.
B. Recommending the use of a breast shield can help draw out inverted nipples, making it easier for the baby to latch onto the breast. Breast shields can be used temporarily until the nipples
become more erect or until breastfeeding techniques are established.
C. Teaching about the use of a breast pump may be appropriate for establishing milk supply or relieving engorgement, but it does not directly address the issue of inverted nipples or difficulty with latching.
D. Offering supplemental formula feedings should be a last resort and should only be considered if other methods of addressing latch difficulties, such as using a breast shield or seeking
assistance from a lactation consultant, have been unsuccessful.

A. Give lactated Ringers IV at 66 mL/hr while NPO B. Vital signs every 4 hours C. Place the child on a continuous cardiopulmonary monitor D. Admit to the pediatric floor for observation E. NPO F. Point of care blood glucose G. Check pedal pulses every 4 hours

Correct Answer is ["A","F"]

Explanation

A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Correct Answer is ["A","F"]

Explanation

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

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)?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

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)?

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

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?