During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?

Correct Answer: A

Rationale: The correct answer is A) Ask for a demonstration of these exercises. This response is appropriate because it allows the nurse to assess the client's understanding of the coughing and deep breathing exercises. By asking for a demonstration, the nurse can ensure that the client is performing the exercises correctly, which is crucial for preventing postoperative complications such as atelectasis and pneumonia. Option B) Explain that coughing should be avoided is incorrect as coughing and deep breathing exercises are actually encouraged after surgery to promote lung expansion, improve oxygenation, and prevent respiratory complications. Option C) Review the client’s previous surgical history is not the most appropriate response in this situation as the client has already mentioned understanding the need for coughing and deep breathing exercises. Focusing on the current teaching and assessment of understanding is more relevant. Option D) Document the client's understanding of teaching is important but not sufficient on its own. While documentation is crucial, it does not actively assess the client's ability to perform the exercises correctly. In an educational context, this scenario highlights the importance of active assessment and validation of patient understanding in the teaching process. By asking for a demonstration, nurses can ensure that patients have the necessary skills and knowledge to care for themselves effectively postoperatively.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Thrombus formation. The nurse should monitor for this complication in the initial 24 hours after a client with unstable asthma undergoes an emergent cardiac catheterization. Rationale: - Thrombus formation is a critical concern post-cardiac catheterization due to the invasive nature of the procedure, which can lead to endothelial damage, platelet activation, and blood stasis—all potential triggers for thrombus development. - Infection (Option B) is a concern post-procedure but typically presents later than the initial 24 hours unless immediate signs are evident such as fever or local redness/swelling. - Bronchospasm (Option C) is more related to the client's asthma condition and may not be directly linked to the cardiac catheterization procedure. - Heart failure (Option D) is not typically an immediate complication post-cardiac catheterization unless pre-existing heart conditions worsen during or after the procedure. Educational context: Understanding post-procedural complications is crucial for nurses caring for pediatric clients with cardiovascular disorders. Monitoring for thrombus formation is essential to prevent life-threatening complications. Nurses must have a solid foundation in pharmacology to anticipate, recognize, and manage potential complications in these high-risk situations.

Correct Answer: A

Rationale: In this scenario, the correct intervention is to patch one eye and then the other every few hours (Option A). This intervention is based on the concept of occlusion therapy, which helps alleviate double vision (diplopia) by blocking the vision from one eye, allowing the brain to focus on the vision from the other eye, thus reducing the perception of double images. Option B, encouraging bedrest until diplopia resolves, is incorrect because bedrest does not address the underlying cause of diplopia and may not be effective in treating this symptom related to multiple sclerosis. Option C, limiting intake of oral fluids, is also incorrect as it is not a relevant intervention for diplopia. Hydration is important, especially in the case of urinary tract infection, but it does not directly address the double vision. Option D, administering artificial tear drops to both eyes, is not the most appropriate intervention for diplopia associated with multiple sclerosis. Artificial tear drops are typically used to relieve dry eyes and do not directly address the visual symptom of double vision. Educationally, understanding the rationale behind the intervention of patching one eye and rotating to the other can help nursing students comprehend the management of diplopia in patients with multiple sclerosis. It reinforces the concept of occlusion therapy and its application in clinical practice to improve patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) Wear braces on both wrists during the night. This teaching is appropriate for a client with bilateral carpal tunnel syndrome experiencing worsened pain and tingling at night. Wrist braces help to keep the wrists in a neutral position, reducing pressure on the median nerve and alleviating symptoms during sleep. This can improve comfort and promote better rest. Option A) Elevating the hands on two pillows at night may provide some relief by reducing swelling, but it does not address the underlying issue of wrist positioning that wrist braces can offer. Option B) Notifying the healthcare provider is important for any significant changes in symptoms or condition, but it does not address the immediate need for symptom management. Option D) Applying cold compresses before bedtime may help with pain relief by numbing the area, but it does not address the mechanical issue of wrist positioning that braces can provide. In an educational context, it's important for nurses to understand the rationale behind interventions for specific conditions like carpal tunnel syndrome in order to provide effective client education. By explaining the benefits of wearing wrist braces to keep the wrists in a neutral position during sleep, nurses can empower clients to manage their symptoms effectively and improve their quality of life.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Auscultate bowel sounds. Following a nephrectomy, abdominal pressure and nausea could indicate a paralytic ileus or bowel obstruction, which are potential postoperative complications. Auscultating bowel sounds is essential to assess for the presence or absence of bowel motility and potential blockages. Option A) Palpating the abdomen may exacerbate any potential complications, such as causing discomfort or rupturing a sensitive area post-surgery. It is not the best initial assessment for this situation. Option B) Measuring hourly urine output is important in monitoring kidney function post-nephrectomy but is not directly related to the presenting symptoms of abdominal pressure and nausea. Option C) Ambulating the client in the hallway may be beneficial for general postoperative recovery but is not the priority in this situation where abdominal symptoms need immediate assessment. Educationally, this question highlights the importance of recognizing potential postoperative complications in patients who have undergone nephrectomy. It emphasizes the need for thorough assessment skills and prioritizing assessments based on the client's symptoms to provide timely and appropriate care.