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A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Provide teaching about the surgical procedure for the client.

Instruct the client's spouse to sign the consent form.

Read the consent form to the client using words the client will understand.

Contact the provider who will be performing the procedure.

Answer and Explanation

The Correct Answer is D

Answer: D. Contact the provider who will be performing the procedure.

Rationale:

A) Provide teaching about the surgical procedure for the client:

While nurses play an essential role in patient education, it is the responsibility of the healthcare provider performing the procedure to ensure the patient fully understands the details, risks, and benefits. Nurses can clarify information but should not provide the initial comprehensive explanation of the procedure.

B) Instruct the client's spouse to sign the consent form:

The client is the one who needs to provide informed consent, not the spouse, unless the client is legally unable to do so. In such cases, legal documentation, such as a power of attorney, is required. Instructing the spouse to sign without proper authorization is inappropriate and potentially legally problematic.

C) Read the consent form to the client using words the client will understand:

While simplifying the language of the consent form can help, it is not sufficient if the client does not fully understand the procedure. Full understanding requires a detailed discussion about the procedure, risks, benefits, and alternatives, which should be done by the provider performing the procedure.

D) Contact the provider who will be performing the procedure:

The provider performing the procedure has the responsibility to ensure the client understands all aspects of the surgery. Contacting the provider to provide a thorough explanation ensures that the client receives accurate and complete information, allowing for truly informed consent.

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Correct Answer is B

Explanation

Choice A rationale:

Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.

Choice B rationale:

Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.

Choice C rationale:

Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.

Choice D rationale:

Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.

A. Prepare an endotracheal tube for intubation. B. Insert a plastic oral airway. C. Provide oxygen using a manual resuscitation bag. D. Perform a head-tilt with chin-lift.

Correct Answer is C

Explanation

Choice A rationale:

Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.

Choice B rationale:

Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.

Choice C rationale:

Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.

Choice D rationale:

Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.

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A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse should identify that which of the following findings indicates that the client has developed a postoperative paralytic ileus?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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