A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, “I cannot do this. I do not want this surgery.” Which of the following actions should the nurse take?

Tell the client about the benefits of the surgery.

Let the client know that their surgeon will be notified of their decision.

Reassure the client that it is expected to be nervous before surgery.

Inform the client that it is too late to stop the surgery.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Let the client know that their surgeon will be notified of their decision.

Choice A Reason:

Telling the client about the benefits of the surgery might seem helpful, but it does not address the client’s immediate concern. The client has expressed a clear decision to refuse the surgery, and the nurse must respect this decision by informing the surgeon. This approach aligns with the ethical principle of respecting patient autonomy.

Choice B Reason:

Letting the client know that their surgeon will be notified of their decision is the correct action. This respects the client’s autonomy and ensures that the surgeon is aware of the client’s wishes. It also allows for further discussion between the client and the surgeon, where the client can receive more detailed information and support.

Choice C Reason:

Reassuring the client that it is expected to be nervous before surgery is supportive but does not address the client’s refusal. While it is important to acknowledge the client’s feelings, the nurse must also take appropriate steps to respect the client’s decision and inform the surgeon.

Choice D Reason:

Informing the client that it is too late to stop the surgery is incorrect and unethical. Patients have the right to refuse treatment at any time, and it is the nurse’s duty to respect and facilitate this decision.

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Correct Answer is A

Explanation

Choice A Reason

Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.

Choice B Reason

Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.

Choice C Reason

Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.

Choice D Reason

Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.

A. Observe the contours of the client’s abdomen using a penlight. B. Determine the presence of bowel sounds by using the diaphragm of the stethoscope. C. Systematically percuss the client’s abdomen. D. Use fingertips to lightly depress the right lower quadrant of the client’s abdomen. E. Press deeply into the client’s upper abdomen left of midline to detect aortic pulsation.

Correct Answer is A,B,C,D,E

Explanation

Choice A reason:

Observing the contours of the client’s abdomen using a penlight is the first step in the abdominal assessment. This step involves inspecting the shape, skin abnormalities, masses, and movement of the abdomen. It is essential to perform this step first to gather initial visual information about the abdomen’s condition before proceeding to other assessment techniques.

Choice B reason:

Determining the presence of bowel sounds by using the diaphragm of the stethoscope is the second step in the abdominal assessment. Auscultation should be performed before percussion and palpation to avoid altering the frequency and intensity of bowel sounds. This step helps assess the presence, frequency, and location of bowel sounds, as well as any vascular sounds.

Choice C reason:

Systematically percussing the client’s abdomen is the third step in the abdominal assessment. Percussion helps assess the presence of tympany or dullness, which can indicate the presence of air, fluid, or solid masses in the abdomen. This step provides valuable information about the underlying structures and any abnormalities.

Choice D reason:

Using fingertips to lightly depress the right lower quadrant of the client’s abdomen is the fourth step in the abdominal assessment. Light palpation helps assess the consistency, tenderness, and presence of any masses or rigidity in the abdomen. This step should be performed after percussion to avoid altering the findings.

Choice E reason:

Pressing deeply into the client’s upper abdomen left of midline to detect aortic pulsation is the fifth and final step in the abdominal assessment. Deep palpation helps assess the presence of any deep-seated masses and the aortic pulsation, which can provide information about the vascular status of the abdomen.

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A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, “I cannot do this. I do not want this surgery.” Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a client’s abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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