Nokea
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
You may also like to solve these questions
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences.
- C. Speak directly to the client.
- D. Use gestures to convey meaning.
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is crucial as it maintains a connection with the client, shows respect, and ensures understanding. Speaking to the interpreter directly can lead to misinterpretation. Speaking slowly (A) may come across as patronizing. Pausing in the middle of sentences (B) can disrupt communication flow. Using gestures (D) may help but should not replace direct verbal communication. The other choices are not as effective in ensuring clear communication and building trust with the client.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This is correct because the proper fit of sequential compression sleeves is essential for effective use. Ensuring that two fingers can fit under the sleeves ensures that they are not too tight, which could impede circulation.
Explanation for why the other choices are incorrect:
A: Assisting the client into a prone position is not necessary for applying sequential compression sleeves.
B: Placing a sleeve over the top of each leg with the opening at the knee is incorrect as the opening should be at the ankle.
D: Setting the ankle pressure at 65 mm Hg is incorrect as pressure settings should be determined based on the individual's needs and the healthcare provider's orders.
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should reflect on their own beliefs and values to ensure they can provide unbiased care. This step is essential to maintain professionalism and respect for the parents' autonomy. It allows the nurse to approach the situation with empathy and understanding.
B: Telling the parents that the procedure is necessary may come off as dismissive of their beliefs and could create conflict.
C: Informing the parents that staff does not require their consent is unethical and goes against the child's and parents' rights. It disregards their autonomy.
D: Contacting a spiritual support person may be helpful, but it should not be the first step. The nurse should first address their own values and then involve spiritual support if needed.
In summary, option A is the best course of action as it promotes respectful and patient-centered care.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. This is the correct action as it validates the client's feelings and provides reassurance that anger is a common emotion when dealing with a cancer diagnosis. By acknowledging the client's emotions, the nurse can build trust and support the client through the grieving process.
A: Discussing risk factors is not the priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage.
C: Providing written information about loss and grief phases may not address the client's current emotional state.
In summary, option D is the best choice as it acknowledges the client's feelings and offers support during a difficult time.