A nurse is caring for a client who has signed consent for the removal of a tumor in the left frontal lobe of the brain. The client states, "The tumor is on the right side of my head." Which of the following actions should the nurse take?
Tell the client to mark the right side of his head with indelible ink.
Contact the surgery department to validate the operative site.
Ask the surgeon to clarify the operative site with the client.
Continue with the surgery because the client already gave informed consent.
The Correct Answer is C
Rationale:
A. It is not appropriate for the client to independently mark the operative site; this could lead to errors. Site marking must be done by the surgical team per protocol.
B. Contacting the surgery department does not directly resolve the client’s confusion or ensure proper informed consent.
C. The surgeon is responsible for confirming and clarifying the surgical site with the client. The nurse should advocate for the client’s safety by notifying the surgeon of the discrepancy.
D. Proceeding with surgery despite the client’s expressed concern would be unsafe and violates the principles of informed consent and patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Rationale:
A. Initiating IV access while a client with dementia is sleeping violates autonomy and informed consent—this is not advocacy.
B. Implementing a plan of care based on nursing goals reflects nursing practice, but advocacy focuses on protecting the client’s rights and wishes, not just following nursing objectives.
C. Providing written information about palliative care supports informed decision-making, which is a key aspect of advocacy.
D. Obtaining an interpreter ensures the client understands their care and can make informed decisions, which is an advocacy action.
E. Documenting a client’s refusal of medication respects and upholds the client’s autonomy, which is a form of advocacy.
Correct Answer is D
Explanation
Rationale:
A. Requesting orientation is appropriate, but it is not the first step when being floated for a single shift.
B. Referring to the resource nurse for client assignments is helpful, but assignments should first be based on demonstrated competencies.
C. Informing the nursing supervisor of lack of experience may be necessary if unsafe assignments are made, but the first action should be to clarify what tasks and skills the nurse is competent to perform.
D. Clarifying competencies with the charge nurse ensures that client assignments are safe and appropriate to the nurse’s skill set, making this the priority action.
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