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 C

Explanation

(A) Review the client's toxicology laboratory report:
While reviewing the toxicology report is important to understand any substances that may have been ingested, it is not the immediate priority compared to ensuring the client's safety.

(B) Administer the Hamilton depression scale:
Administering the Hamilton depression scale can help assess the severity of the client's depression, but immediate safety measures take precedence over assessment tools upon admission after a suicide attempt.

(C) Initiate one-to-one nursing observation:
Initiating one-to-one nursing observation is the most immediate and crucial action to ensure the client's safety. After a suicide attempt, continuous observation is essential to prevent further self-harm and ensure the client's immediate safety.

(D) Make a contract with the client for weight gain:
While addressing anorexia nervosa and making a contract for weight gain is important for the client's long-term treatment plan, it is not the first priority. Ensuring immediate safety through continuous observation is the most critical initial step.

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

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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