A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?

"I will make a note in your medical record that you don't understand the surgery."

"I will tell your provider that you have questions about the surgery."

"Would you like to hear about some other possible treatment options?"

"Would you like me to tell you more about the procedure?"

Answer and Explanation

The Correct Answer is B

A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.

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Correct Answer is C

Explanation

A. Plan for your son to meet his sister for the first time at home. This is incorrect because allowing the sibling to visit the newborn in the hospital can help with early bonding and ease the transition.
B. Give your son plenty of "alone time" with his sister. This is incorrect because young children require supervision around infants to ensure safety.
C. Give your son a little gift from his new sister. This is correct because presenting a small gift from the baby helps the older sibling feel included and fosters a positive association with the new arrival.
D. Hold your daughter when your son first meets her. This is incorrect because allowing the older sibling to greet the parent first before introducing the baby can help them feel reassured and less displaced.

A. Tachypnea B. Ketonuria C. Warm skin D. Nervousness

Correct Answer is D

Explanation

A. Tachypnea. Rapid breathing is associated with diabetic ketoacidosis (DKA) rather than mild hypoglycemia.
B. Ketonuria. The presence of ketones in the urine occurs with prolonged hyperglycemia and DKA, not with hypoglycemia.
C. Warm skin. Hypoglycemia typically causes cool, clammy skin due to sympathetic nervous system activation, not warmth.
D. Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating.

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A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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