Nokea
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
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The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?
- A. Inform the client's assigned nurse that the client is back in his or her room.
- B. Intercept the client and check the client's name band for a room number.
- C. Stop the client and ask for his or her name and the assigned room number.
- D. Ask the nearby UAP to help the client back into the room with the sign posted.
Correct Answer: B
Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.
Padding on a restraint helps:
- A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. the client feel more secure.
- C. to keep infection and wounds down.
- D. to keep restraints in place.
Correct Answer: A
Rationale: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.
Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities.
- B. a tender, rigid abdomen.
- C. vomiting bile.
- D. bruising.
Correct Answer: C
Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.
When entering the client's room, the nurse sees that the client is standing on the far side of the room with clothing on fire. Which action should be taken by the nurse immediately?
- A. Go find the nearest fire alarm box
- B. Grab a blanket to smother the fire
- C. Obtain water to douse the clothes
- D. Tell the client to drop and roll on the floor
Correct Answer: D
Rationale: Instructing the client to drop and roll immediately smothers the flames, addressing the fire on the client's clothing most effectively.
A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.