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A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, 'I just want this over.' What should the nurse do to promote a positive surgical outcome for the patient?
- A. Ask the patient what her specific concerns are about the surgery.
- B. Reassure the patient that the surgery will be over soon and she will be fine.
- C. Redirect the patient's attention to the necessary preoperative preparations.
- D. Tell the patient she should not be so anxious because she is having a common, safe surgery.
Correct Answer: A
Rationale: Understanding the patient's specific concerns allows the nurse to address fears directly, promoting a positive outcome.
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Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site.
- B. Irrigate with 5 mls of 0.9% Normal Saline.
- C. Palpate for a thrill over the fistula.
- D. Check color and warmth in the extremity.
Correct Answer: C
Rationale: A thrill confirms blood flow through the fistula.
Which standardized nursing terminologies specifically relate to the steps of the nursing process (select all that apply)?
- A. Omaha System
- B. Nursing Outcomes Classification (NOC)
- C. Nursing Interventions Classification (NIC)
- D. NANDA International: Nursing Diagnoses
Correct Answer: B
Rationale: NOC, NIC, and NANDA International directly correspond to the steps of the nursing process: outcomes, interventions, and diagnoses.
A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed
occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
- A. "We can teach you some relaxation techniques to minimize your pain."
- B. "Keep wire cutters with you at all times."
- C. "Use a water pick device to keep your teeth clean."
- D. "Consume a high-protein, liquid diet."
Correct Answer: B
Rationale: The correct answer is B: "Keep wire cutters with you at all times." This is the priority statement because in the event of an emergency, such as airway obstruction or trauma, quick access to wire cutters is crucial to ensure timely removal of the jaw fixation wires. Without immediate access to wire cutters, the client may suffer serious complications.
Incorrect choices:
A: "We can teach you some relaxation techniques to minimize your pain." - While pain management is important, it is not the priority in this situation where the immediate risk is airway compromise.
C: "Use a water pick device to keep your teeth clean." - Oral hygiene is important but not as critical as ensuring access to wire cutters for emergency situations.
D: "Consume a high-protein, liquid diet." - Nutrition is important for healing but is not as time-sensitive as having wire cutters readily available in case of an emergency.
The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing?
- A. Witnessing the patient's signature
- B. Obtaining informed consent from the patient for the surgery
- C. Verifying that the consent for surgery is truly voluntary and informed
- D. Ensuring that the patient is mentally competent to sign the consent form
Correct Answer: A
Rationale: The nurse acts as a witness to the patient's signature on the consent form, verifying that it was signed voluntarily.