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A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, 'I am very nervous and scared to have surgery.' What client outcome is the priority?
- A. Evaluate the need for antibiotics.
- B. Resolve the client’s anxiety.
- C. Provide preoperative education.
- D. Prepare the client for surgery.
Correct Answer: B
Rationale: The correct answer is B: Resolve the client’s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.
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The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?
- A. Insulin is absorbed more slowly at abdominal injection sites than at other sites.
- B. Insulin absorbed rapidly regardless of the injection site.
- C. Insulin is absorbed more rapidly at abdominal injection than at other sites.
- D. Insulin is absorbed unpredictably at all injection sites.
Correct Answer: C
Rationale: Rationale:
1. Abdominal injection sites have a higher blood supply, leading to faster absorption.
2. Insulin absorption is faster in areas with more blood vessels.
3. Rapid absorption at the abdomen results in quicker onset of action.
4. Other sites may have slower absorption due to less blood flow.
Summary:
A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow.
B: Incorrect. Absorption varies based on injection site blood supply.
C: Correct. Abdominal injection sites have rapid insulin absorption.
D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
- A. The nurse should practice interviewing strategies.
- B. The nurse should modify the data collection tool.
- C. The nurse should determine specific purpose of data collection.
- D. The nurse should update the database.
Correct Answer: A
Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details.
Summary:
B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview.
C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning.
D: Updating the database is irrelevant to the problem of inadequate data collection during client history.
Which of the ff vessels is often used for grafting?
- A. The basic and cephalic veins in the arm
- B. The internal mammary and internal thoracic arteries in the chest
- C. The saphenous vein in the leg
- D. The radial artery in the arm
Correct Answer: B
Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
Which finding will alert the nurse that the goal has been met?
- A. Heart rate 78 beats/min on 12/3
- B. Heart rate 78 beats/min on 12/4
- C. Heart rate 80 beats/min on 12/3
- D. Heart rate 80 beats/min on 12/4
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.