A nurse enters a client’s room to obtain informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

Educate the client about the risks of refusing the procedure

Complete an incident report

Inform the provider that the client requires clarification about the procedure

Answer the client’s questions concerning the procedure

Answer and Explanation

The Correct Answer is C

a.   While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b.   Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c.   When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d.   While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.

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Correct Answer is A

Explanation

a. Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b. Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c. Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d. While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.

A. “I am not sure how I will pay for all the therapy I will need” B. “I hope I can adjust to using crutches while I am recovering” C. “I just don’t think I can handle looking at my leg” D. “I am worried about taking care of my toddler at home”

Correct Answer is D

Explanation

a. Concerns about paying for therapy may indicate financial worries but do not necessarily suggest a need for occupational therapy specifically.
b. Expressing hope to adjust to using crutches is a common concern for post-amputation clients but does not specifically indicate a need for occupational therapy.
c. Difficulty accepting the appearance of the amputated limb may indicate a need for psychological support or counseling rather than occupational therapy.
d. Concerns about caring for a toddler at home following amputation may involve tasks that require adaptation and assistance, such as mobility, childcare activities, and home safety, which are within the scope of occupational therapy.

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A nurse enters a client’s room to obtain informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

Correct Answer is D

Explanation

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A nurse enters a client’s room to obtain informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

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