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A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
- A. Assess the client for anxiety
- B. Break the information into smaller bits
- C. Give the client written information
- D. Request the provider to repeat the information
Correct Answer: A
Rationale: Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.
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A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the client are being met?
- A. Drain output is clear and minimal
- B. Drain site is red and swollen
- C. Drain is clogged and not draining
- D. Client reports severe pain at drain site
Correct Answer: A
Rationale: A clear and minimal drain output indicates that the surgical site is healing appropriately and there is no significant infection or fluid accumulation. Redness and swelling, a clogged drain, or severe pain could indicate complications such as infection or obstruction, which would require further intervention.
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort?
- A. Allow the client to assume a position of comfort
- B. Allow the client's family to remain at the bedside
- C. Give the client a warm, non-carbonated drink
- D. Provide warm blankets or cool blankets as desired
- E. Pull the curtains around the bed to provide privacy
Correct Answer: A,B,D,E
Rationale: There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats per minute and now needs a beta blocker. The student asks why this was needed. What response by the nurse is best?
- A. Tachycardia increases the workload of the heart
- B. Tachycardia requires less oxygen delivery
- C. A high heart rate reduces cardiac effort
- D. A high heart rate prevents surgical stress
Correct Answer: A
Rationale: Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
- A. Married young adult who is the primary caregiver for children
- B. Middle-aged client who is post long time replacement, needs physical therapy
- C. Older adult who lives at home despite some memory loss
- D. Young client who lives alone, has family and friends nearby
Correct Answer: C
Rationale: The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
- A. It helps prevent ulcers from the stress of the surgery
- B. It reduces stomach acid to prevent aspiration
- C. Since you don't have ulcers, I will have to ask
- D. The physician prescribed this medication for you
Correct Answer: B
Rationale: Ranitidine (Zantac) is given preoperatively to reduce gastric acid production, which lowers the risk of aspiration during surgery. This is the most accurate explanation. Preventing ulcers is not the primary purpose in this context, and the other options do not provide a clear rationale.