Page 503 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Foundations of Care: Perioperative Care
Health Problem: Adult Health: Gastrointestinal: Upper GI Disorders
Priority Concepts: Ethics; Health Care Law
Reference: Potter et al. (2017), p. 310.

130. Answer: 3

Rationale: Explanations should begin with the information that the client knows.
By providing the client with individualized explanations of care and procedures, the
nurse can assist the client in handling anxiety and fear for a smooth preoperative
experience. Clients who are calm and emotionally prepared for surgery withstand
anesthesia better and experience fewer postoperative complications. Option 1 does
not focus on the client’s anxiety. Explaining the entire surgical procedure may
increase the client’s anxiety. Option 4 avoids the client’s anxiety and is focused on
postoperative care.
Test-Taking Strategy: Note that the client expresses anxiety. Use therapeutic
communication techniques. Note that the question contains strategic words, most
likely, and also note the words stimulate further discussion. Also use the steps of the
nursing process. The correct option addresses assessment and is the only
therapeutic response.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Foundations of Care: Perioperative Care
Health Problem: Mental Health: Therapeutic Communication
Priority Concepts: Anxiety; Communication
Reference: Ignatavicius, Workman, Rebar (2018), pp. 237, 246.

131. Answer: 4

Rationale: For optimal lung expansion with the incentive spirometer, the client
should assume the semi-Fowler’s or high-Fowler’s position. The mouthpiece should
be covered completely and tightly while the client inhales slowly, with a constant
flow through the unit. The breath should be held for 5 seconds before exhaling
slowly.
Test-Taking Strategy: Focus on the subject, correct use of an incentive spirometer,
and visualize the procedure. Note the words rapidly, loose, and 15 seconds in the
incorrect options. Options 1, 2, and 3 are incorrect steps regarding incentive
spirometer use.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Skills: Perioperative Care
Health Problem: N/A
Priority Concepts: Client Education; Gas Exchange
Reference: Ignatavicius, Workman, Rebar (2018), pp. 243-244.

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