A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?

Describe the surgery and what the client will experience postoperatively.

Reinforce information at the client's level of understanding.

Reassure the client that the surgery rarely has any negative outcomes.

Notify the client's family of the plan of care.

Answer and Explanation

The Correct Answer is B

A) Describe the surgery and what the client will experience postoperatively:
While it is essential to provide information about the surgery and the postoperative experience, the primary focus of preoperative teaching is to ensure that the client understands the information provided. This option does not specifically address the client's level of understanding, which is crucial for effective teaching.

B) Reinforce information at the client's level of understanding:
This is the correct choice. When contributing to the preoperative teaching plan, the nurse should ensure that information is provided in a way that the client can comprehend. Reinforcing information at the client's level of understanding enhances communication and ensures that the client is well-informed about the procedure and what to expect.

C) Reassure the client that the surgery rarely has any negative outcomes:
While it is important to provide reassurance and support to the client, it is not appropriate to make promises or provide guarantees about the outcome of the surgery. Surgery, by its nature, carries risks, and it is essential to provide the client with accurate information while maintaining a supportive and empathetic approach.

D) Notify the client's family of the plan of care:
While it is important to involve the client's family in the plan of care, the primary focus of preoperative teaching is on the client. Involving the family in the plan of care is important, but it is not the most immediate action in the context of preoperative teaching.

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Correct Answer is D

Explanation

A. A 14-month-old toddler with bruises on bony prominences:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to falls. While bruising can raise concerns, it is not necessarily indicative of physical abuse, especially in this age group.

B. A 9-month-old infant who sustained near drowning:

Near drowning in an infant who climbed into the tub and turned on the water suggests an accidental event rather than physical abuse. This scenario is consistent with lack of supervision or an unfortunate accident.

C. A 3-year-old toddler with scalding burns:

Scalding burns from spilling hot tea on oneself can occur accidentally, especially in young children who may not understand the dangers associated with hot liquids. While the circumstances may raise suspicion, it does not necessarily indicate physical abuse without further evidence.

D. A 6-year-old child with a spiral fracture:

A spiral fracture of the tibia and fibula is concerning for physical abuse, especially in a child who reportedly sustained the injury while riding a bicycle. Spiral fractures are often associated with twisting or pulling forces and are considered suspicious for non-accidental trauma, particularly when there is no plausible explanation for the injury.

A. Restlessness B. Hyperactive bowel sounds C. Decreased deep-tendon reflexes D. Bounding peripheral pulses

Correct Answer is C

Explanation

A. Restlessness:

Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.

B. Hyperactive bowel sounds:

Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.

C. Decreased deep-tendon reflexes:

Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.

D. Bounding peripheral pulses:

Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.

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A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?

Nursing Test Bank

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