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 B

Explanation

A. Data collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, sociocultural, and spiritual factors. While data collection is essential for planning, in this scenario, the nurse is already involved in the collaborative process of preparing a discharge plan, indicating the phase of planning.

B. Planning:

Planning involves developing a comprehensive plan of care based on the assessment data collected. It includes setting priorities, establishing goals, identifying interventions, and coordinating resources to meet the client's needs. In this scenario, the nurse, social worker, and physical therapist are working together to plan the client's discharge, which involves determining the appropriate support, resources, and interventions needed for a successful transition.

C. Evaluation:

Evaluation occurs after implementation, where the nurse assesses the client's response to the interventions implemented and determines whether the goals and outcomes have been achieved. While evaluation is an essential part of the nursing process, it occurs after planning and implementation.

D. Implementation:

Implementation involves carrying out the plan of care developed during the planning phase. It includes initiating interventions, providing treatments, and coordinating care to meet the client's needs. In this scenario, the nurse, social worker, and physical therapist are in the process of developing the discharge plan, which precedes implementation.

A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis

Correct Answer is D

Explanation

(A) Metabolic alkalosis: This condition is characterized by a high blood pH (>7.45) and a high bicarbonate level (>26 mEq/L). The client’s pH and bicarbonate levels are both lower than normal, which rules out metabolic alkalosis.

(B) Respiratory acidosis: This condition is characterized by a low blood pH (<7.35) and a high PaCO2 level (>45 mm Hg). Although the client’s pH is low, the PaCO2 level is also low, which rules out respiratory acidosis.

(c) Respiratory alkalosis: This condition is characterized by a high blood pH (>7.45) and a low PaCO2 level (<35 mm Hg). The client’s pH is low, which rules out respiratory alkalosis.

(D) Metabolic acidosis: This condition is characterized by a low blood pH (<7.35) and a low bicarbonate level (<22 mEq/L). The client’s pH is 7.26 and bicarbonate level is 14 mEq/L, both of which are lower than normal. This indicates metabolic acidosis, which is common in clients with acute kidney injury as the kidneys are unable to excrete hydrogen ions and reabsorb bicarbonate. Therefore, the nurse should identify that the client is experiencing metabolic acidosis.

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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 working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute kidney injury. The client's ABGS are: PH:7.26 PaCO2: 30 mm Hg HCO3: 14 mEq/L Which of the following acid-imbalances should the nurse identify the client is experiencing?

Correct Answer is D

Explanation

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