a nurse is caring for a client who is scheduled for surgery the client expresses fear of the surgery which response should the nurse make

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A client expresses fear of surgery. Which response should the nurse make?

A. Explain the risks of the surgery in detail.
B. Tell the client that many clients feel anxious before surgery.
C. Reassure the client that the surgical team is highly experienced.
D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

2. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

A. Administer the immunization in the deltoid muscle
B. Apply a cold compress to the injection site
C. Apply pressure to the injection site for 5 minutes
D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

3. A client who has glaucoma and a new prescription for timolol eyedrops is receiving teaching from a nurse. Which of the following statements indicates an understanding of the teaching?

A. I will place the eye drops in the center of my eye.
B. I will place pressure on the corner of my eye after using the drops.
C. I should expect my tears to turn red after using the drops.
D. I should expect the drops to appear cloudy.

Correct answer: B

Rationale: The correct answer is B because placing pressure on the corner of the eye after using the drops helps in better absorption. Option A is incorrect because eye drops should be placed in the conjunctival sac, not the center of the eye. Option C is incorrect because tears turning red is not an expected outcome of using timolol eyedrops. Option D is incorrect because timolol eyedrops should not appear cloudy.

4. A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?

A. Blood pressure of 118/76 mm Hg
B. Heart rate of 88/min
C. Urinary output of 30 mL/hr
D. Hematocrit 42%

Correct answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

5. Which electrolyte imbalance is most concerning for a patient on furosemide?

A. Hypokalemia
B. Hyponatremia
C. Hyperkalemia
D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss through increased urinary excretion, making hypokalemia the most concerning electrolyte imbalance. Hyponatremia (Choice B) is not typically associated with furosemide use. Hyperkalemia (Choice C) is less likely due to furosemide's potassium-wasting effect. Hypercalcemia (Choice D) is not a common electrolyte imbalance seen with furosemide.