A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

"This can help prevent nausea."

"This can help prevent pneumonia."

"I should do this every 4 hours."

"I should do this to keep my heart from beating too fast."

Answer and Explanation

The Correct Answer is B

A.   "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B.   "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C.   "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D.   "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.

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Correct Answer is C

Explanation

A: Asking the client why they are angry may come across as confrontational and defensive, potentially escalating the situation. It does not promote open communication or therapeutic rapport.
B: Sharing personal information about diabetes running in the nurse's family is not relevant to the client's feelings or concerns and may not be helpful in addressing the client's anger.
C: Correct. Acknowledging the client's feelings of anger and offering to sit down and talk provides an opportunity for therapeutic communication. This response demonstrates empathy and a willingness to listen and address the client's concerns about insulin therapy.
D: While it is true that insulin therapy can help reduce the risk of complications in type 2 diabetes, this response may come across as dismissive of the client's feelings and concerns. It does not address the emotional aspect of the client's anger.

A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.

Correct Answer is B

Explanation

A. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

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A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

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