A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?
Delay the admission while the client fills out the facility’s advance directives form.
Confirm with the client’s family that the consent form has been signed.
Explain to the client that signing the facility’s consent form means they cannot refuse care.
Determine if the client has prepared their advance directives.
The Correct Answer is D
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.
Correct Answer is D
Explanation
Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.
Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.
Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.
Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.
Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.
Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.
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