The post-surgical client has been NPO this shift; however, the physician orders clear liquids. Which of the following actions would be best on the part of the nurse?

Correct Answer: C

Rationale: Starting with small sips of water allows the nurse to assess the client's tolerance to fluids after being NPO, preventing nausea or complications.

Correct Answer: B

Rationale: By stating that she is not in his situation, the nurse is using the therapeutic communication technique of validation, whereby she shows sensitivity to the meaning behind his behavior. She is also creating a supportive and nonjudgmental environment, and inviting him to express his frustrations. Telling the patient to try a distraction dismisses the client's feelings and gives common advice instead of expert advice. Saying she knows what clients feel is presumptive and inappropriate.

Correct Answer: D

Rationale: A tennis player will use one arm primarily and unilateral hypertrophy will most likely result. Lifting weights, moving furniture, and playing soccer will most likely result in bilateral muscle hypertrophy.

Correct Answer: B

Rationale: The aortic valve is best auscultated at the second intercostal space (ICS) just right of the sternum. This is because the aortic valve is located in the second intercostal space on the right side of the sternum.

Correct Answer: A

Rationale: A nonthreatening topic will establish rapport and trust between client and nurse. Non-directive questions may allow avoidance of key details, and forms or rigid questioning hinder therapeutic rapport.