A nurse is assisting in the care of a client who is scheduled for surgery.

Exhibits
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

History of diabetes mellitus

Prealbumin level

Cholesterol level

Mini Nutritional Assessment screening tool score

History of malnutrition

History of hyperlipidemia

Answer and Explanation

Correct Answer : A,B,D,E

A. History of diabetes mellitus: Diabetes causes impaired blood flow and neuropathy, which delay wound healing by reducing oxygen and nutrient delivery to tissues and increasing infection risk.

B. Prealbumin level: A low prealbumin level reflects inadequate protein stores, which are critical for cellular repair, immune function, and the synthesis of collagen during wound healing.

C. Cholesterol level: While elevated cholesterol increases cardiovascular risk, it does not directly affect the biochemical processes involved in wound healing or tissue repair.

D. Mini Nutritional Assessment screening tool score: A low score indicates poor nutritional status, often linked with deficiencies in vitamins, minerals, and protein that are necessary for effective tissue repair and immune response.

E. History of malnutrition: Malnutrition results in diminished energy reserves and nutrient deficiencies, both of which weaken the body's capacity to regenerate tissue and fight infections, prolonging wound healing time.

F. History of hyperlipidemia: Hyperlipidemia contributes to atherosclerosis but is not directly associated with impaired wound healing or immune function necessary for tissue recovery.

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Correct Answer is A

Explanation

A. "I will be told about alternative procedures before I'm asked to sign the consent form." Understanding alternative options is a key component of informed consent. Clients must be informed about the risks, benefits, and alternatives to the proposed procedure so they can make a voluntary, educated decision.

B. "My nurse is responsible for obtaining informed consent." While nurses often witness the client’s signature and may provide teaching, the responsibility for obtaining informed consent legally lies with the provider performing the procedure, who must explain the details and answer questions.

C. "Once I sign the consent form, I cannot change my mind about having the procedure." Clients retain the right to withdraw consent at any time before the procedure begins. Signing the form does not waive this right, and they can refuse or delay the procedure if they choose.

D. "The consent form will include the estimated time for my recovery from the procedure." Recovery time is usually discussed during preoperative teaching but is not a required element of the consent form itself. The form primarily covers procedure details, risks, and alternatives.

A. Prick the side of the client's finger. B. Squeeze the client's finger until a blood drop forms. C. Elevate the client's hand above the level of the heart. D. Apply clean gloves. E. Cleanse the client's finger with an iodine swab.

Correct Answer is ["A","D"]

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

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A nurse is assisting in the care of a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for a surgical procedure. Which of the following statements by the client indicates an understanding of the informed consent process?

Correct Answer is A

Explanation

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

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A nurse is assisting in the care of a client who is scheduled for surgery.

Exhibits
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.