A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?
Inform the client they cannot refuse the surgery once the consent form has been signed.
Explain the risks of the surgery to the client.
Ensure the client has advance directives on file.
Ask the client if they wish to be resuscitated in the event they stop breathing.
The Correct Answer is C
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client if they understand the procedure. The nurse’s role in informed consent is to confirm that the client understands the procedure and voluntarily agrees to it. If the client has questions or does not understand, the nurse should notify the provider for further explanation.
B. Describe the procedure to the client. It is the provider’s responsibility to explain the procedure in detail, including what it entails. The nurse should not provide this explanation.
C. Inform the client about alternative treatment options. The provider must discuss alternative treatment options, not the nurse. The nurse can ensure that this discussion has occurred but does not provide the alternatives.
D. Explain the risks of the procedure to the client. The provider is responsible for explaining the risks, benefits, and expected outcomes of the procedure. The nurse’s role is to witness the consent and ensure the client understands.
Correct Answer is ["A","B","C"]
Explanation
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
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