While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?
Attempt to distract the client with general conversation.
Explain the procedure in detail while removing the staples.
Encourage the client to continue to verbalize the anxiety.
Reassure the client that this is a simple nursing procedure.
The Correct Answer is A
A. Attempting to distract the client with general conversation can help redirect the client's focus away from the discomfort and anxiety associated with the procedure. It can help alleviate anxiety and make the experience more tolerable for the client.
B. Explaining the procedure in detail while removing the staples may increase the client's anxiety and discomfort. While education about the procedure is important, it may not be the most
effective intervention in this situation.
C. Encouraging the client to continue to verbalize the anxiety acknowledges the client's feelings but may not effectively address the anxiety or alleviate discomfort during the procedure.
D. Reassuring the client that this is a simple nursing procedure may not be sufficient to alleviate the client's anxiety. The client's perception of the procedure as distressing is valid, and additional measures may be needed to help manage the anxiety and discomfort.
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Related Questions
Correct Answer is C
Explanation
A. Monitor and document strict intake and output: While monitoring intake and output is
important in managing fluid balance, it may not directly address the potential complications associated with hyperkalemia and hyperglycemia.
B. Assess the serum potassium level every 4 hours: While monitoring potassium levels is important, obtaining a 12-lead electrocardiogram provides immediate information about the cardiac effects of hyperkalemia, which can be life-threatening.
C. Obtain a 12-lead electrocardiogram daily: Hyperkalemia can lead to serious cardiac arrhythmias, including bradycardia, heart block, and ventricular fibrillation. Daily
electrocardiograms can help detect these changes early.
D. Evaluate glucose levels before and after meals: While monitoring glucose levels is important, the immediate concern in this scenario is the potential cardiac effects of hyperkalemia.
Correct Answer is A
Explanation
A. Observing the color of urine is crucial when monitoring for adverse effects of prasugrel, as one of the potential adverse effects is bleeding. Hematuria (blood in the urine) can indicate
bleeding complications, which require immediate attention.
B. Assessing skin turgor is not directly related to monitoring for adverse effects of prasugrel.
Skin turgor assessment is typically used to assess hydration status.
C. Measuring body temperature is important for monitoring for signs of infection or inflammation but is not directly related to monitoring for adverse effects of prasugrel.
D. Checking for pedal edema is not directly related to monitoring for adverse effects of
prasugrel. Pedal edema may indicate issues such as fluid overload or venous insufficiency.
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