A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

"You have nothing to worry about."

"Others who have had this procedure have had great results."

"Why are you feeling so anxious?"

"Tell me more about your concerns."

Answer and Explanation

The Correct Answer is D

A. Dismissing the client's feelings does not address the client's anxiety.
B. Comparing the client to others does not address her individual concerns and may feel dismissive.
C. Asking "why" questions can come across as judgmental and may not encourage open communication.
D. Encouraging the client to express her concerns is a therapeutic communication technique that validates her feelings and can help reduce anxiety.

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Correct Answer is C

Explanation

A. A client with a hemi-colectomy and colostomy is not at highest risk for aspiration.
B. A client with a chest tube may have respiratory issues but is not at the highest risk for aspiration.
C. A client receiving continuous enteral feeding through an NG tube is at the highest risk for aspiration due to the risk of feeding contents entering the airway.
D. A client with Crohn's disease and an ileostomy is not at the highest risk for aspiration.

A. Provide assistance to bathroom. B. Increase fluids. C. Perform a bladder scan. D. Insert a straight catheter.

Correct Answer is C

Explanation

A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.

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A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?

Correct Answer is C

Explanation

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