A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Discuss if family members will assist with postoperative care

Determine what the client knows about the surgery

Review the client’s current home environment

Identify the client’s usual coping mechanisms

Answer and Explanation

The Correct Answer is B

Choice A reason: Discussing family assistance for postoperative care is important for discharge planning but not the priority preoperatively. Understanding the client’s knowledge ensures informed consent and addresses immediate educational needs, making this choice secondary.

Choice B reason: Determining the client’s knowledge about the surgery is the priority, as it ensures informed consent, a legal and ethical requirement. It identifies misconceptions, reduces anxiety, and promotes compliance, directly impacting surgical preparation, making this the correct choice.

Choice C reason: Reviewing the home environment is relevant for discharge planning, not preoperative care. It does not address immediate surgical preparation needs like understanding the procedure, making this choice less urgent than assessing knowledge.

Choice D reason: Identifying coping mechanisms supports emotional preparation but is not the priority. Ensuring the client understands the surgery is critical for consent and cooperation, making this choice secondary to assessing their knowledge.

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Correct Answer is B

Explanation

Choice A reason: Right vs. wrong is a moral or ethical framework, not a clinical concept for understanding stressors. It does not address the psychological or physiological responses to stress, making it irrelevant for developing nursing care context.

Choice B reason: Adaptive vs. maladaptive responses to stressors determine how stress affects mental and physical health. Adaptive coping promotes resilience, while maladaptive responses, like avoidance, worsen outcomes, providing critical context for nursing care, making this the correct choice.

Choice C reason: Good vs. bad is a subjective judgment, not a scientific concept for stress responses. It lacks the specificity to guide nursing care for stress-related health impacts, making this choice inappropriate for clinical context.

Choice D reason: Justified vs. unjustified is a legal or ethical concept, not relevant to stress response assessment. It does not address the physiological or psychological effects of stressors, making it incorrect for nursing care planning.

A. pH 7.45 B. Potassium 3.3 mEq/L C. PaCO2 50 mmHg D. HCO3- 30 mEq/L

Correct Answer is C

Explanation

Choice A reason: A pH of 7.45 is within the normal range (7.35-7.45) and indicates no acidosis. Respiratory acidosis results from CO2 retention, lowering pH below 7.35 due to hypoventilation. This normal pH value does not reflect the acid-base imbalance expected in respiratory acidosis.

Choice B reason: Potassium 3.3 mEq/L indicates hypokalemia, not directly related to respiratory acidosis. Respiratory acidosis may cause hyperkalemia due to hydrogen ion buffering, shifting potassium out of cells. This low potassium level is not a typical finding in respiratory acidosis scenarios.

Choice C reason: PaCO2 of 50 mmHg (normal 35-45 mmHg) indicates CO2 retention, the hallmark of respiratory acidosis. Hypoventilation, often from lung disease or airway obstruction, elevates PaCO2, lowering blood pH below 7.35, confirming the acid-base imbalance expected in this condition.

Choice D reason: HCO3- of 30 mEq/L (normal 22-26 mEq/L) suggests metabolic compensation for chronic respiratory acidosis but is not the primary finding. Respiratory acidosis is defined by elevated PaCO2, not HCO3-, which increases later as the kidneys retain bicarbonate to buffer acidity.

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A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

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