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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Holding hands below elbows when rinsing is a correct technique to prevent contamination of washed hands.
B. Lathering using a circular movement is a correct technique for thorough handwashing.
C. Washing for a total of 20 seconds is in line with the recommended duration for effective handwashing.
D. Turning the water off using bare hands can potentially recontaminate the hands. Instead, a paper towel or elbow should be used to turn off the faucet after washing hands to prevent recontamination. Therefore, this action by the UAP requires additional teaching.

A. Find a comfortable area that the parents can wait that is close to the procedure area B. Provide the parents with ideas about how to make their child feel better after the procedure C. Tell the parents that the procedure is 100% effective and safe D. Limit visitation as long as the parents are anxious E. Do not give any specifics on the amount of time the procedure will take

Correct Answer is ["A","B"]

Explanation

A. Comfortable waiting areas can help parents feel more at ease during their child's procedure, as proximity may provide a sense of reassurance.
B. Information on post-procedure care can empower parents to take an active role in their child's recovery, which can be comforting.
C. It is unethical and incorrect to guarantee that any medical procedure is 100% effective and safe; complications can arise, and setting realistic expectations is crucial.
D. Limiting visitation can increase anxiety as it separates parents from their child, which can be distressing for both the child and the parents.
E. Providing a general timeframe for the procedure can help manage expectations and reduce anxiety, rather than leaving the parents to worry about an indefinite wait.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is D

Explanation

Exhibits What can the nurse do to help the parents to decrease their anxiety? Select all that apply.

Correct Answer is ["A","B"]

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

The nurse notes that a client is receiving a heparin infusion labeled, Heparin Sodium 25,000 Units in 5% Dextrose Injection, 500 mL at a rate of 50 mL/hour. What dose of heparin is the client receiving per hour? (Enter the numerical value only.)

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The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?