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A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.

The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.

Which of the following statements is the best response from the nurse?

“This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”.

“The most important thing is that now you are here, and it is going to get taken care of.”.

“I will be happy to go and get you some reading materials about this procedure to explain it further.”.

“It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.

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Correct Answer is A

Explanation

Choice A rationale
Handling the cast with the palms of the hands is recommended, especially when the cast is still wet and not fully hardened. This helps to avoid indentations and pressure points that could lead to discomfort or skin complications.
Choice B rationale
Drying the cast with a hair dryer is not typically recommended. Excessive heat can cause the cast material to weaken and can also burn the skin.
Choice C rationale
Keeping the casted leg in a dependent position is not recommended. This can lead to increased swelling and discomfort.
Choice D rationale
Covering the patient’s legs with a blanket is not specifically related to the care of a fresh cast. While it may provide comfort, it does not have a direct impact on the care or outcome of the cast.

A. A patient hospitalized with acute pancreatitis and is sitting in a high Fowler’s position leaning over the bedside table. B. A patient who had bariatric surgery and is reporting shoulder pain and heart racing. C. A patient who is one day post-op after an intestinal resection and colostomy, and has no effluent in the bag. D. A patient with cirrhosis and is reporting loose stools.

Correct Answer is B

Explanation

Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.

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A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.

The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.

Which of the following statements is the best response from the nurse?