A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

"How are things going at your job?"

"Why do you think this is happening to you?"

"You must he feeling very frightened right now."

"Maybe you should think more positively."

Answer and Explanation

The Correct Answer is C

A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.

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Correct Answer is D

Explanation

A. Shake both insulin vials for 2 min before withdrawing the doses. Insulin vials should never be shaken, as this can create air bubbles and affect dosage accuracy. NPH insulin should be gently rolled between the hands to mix.
B. Administer the mixture within 5 min of preparing it. While insulin should be administered promptly, there is no strict 5-minute requirement.
C. Withdraw the NPH insulin before the regular insulin. Regular insulin should be drawn up first to prevent contamination with the cloudy NPH insulin.
D. Inject air into the regular insulin vial before injecting air into the NPH vial. Air should be injected into the regular insulin first, then into the NPH insulin vial, before withdrawing the doses in the correct order.

A. Wire cutters B. Padded clamp C. Montgomery straps D. Tracheostomy tray

Correct Answer is B

Explanation

A. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.

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A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." 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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Correct Answer is B

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