A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

Ask the surgeon to discuss the procedure with the client.

Explain the procedure in detail to the client.

Encourage the client to reread the consent form before signing.

Tell the client that the surgeon will explain it to him in the operating room.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

It's essential to ensure that the client fully understands the surgical procedure and its implications before signing the informed consent form. If the client expresses confusion or lack of understanding, the nurse should involve the surgeon to address the concerns directly. The surgeon is the most appropriate person to provide comprehensive information about the procedure, potential risks, benefits, and alternatives. This promotes patient autonomy and informed decision-making, aligning with ethical principles.

Choice B rationale:

While educating the client about the procedure is important, it's not the nurse's role to provide detailed explanations of surgical procedures. Additionally, the surgeon possesses the necessary expertise to explain medical procedures accurately. Relying on the surgeon for this explanation maintains professional boundaries and ensures accurate information dissemination.

Choice C rationale:

Encouraging the client to reread the consent form is insufficient if the client did not initially understand the explanation. The consent form might contain complex medical language, and the client might need direct communication with the surgeon to address specific concerns. Merely re-reading the form might not alleviate the client's confusion.

Choice D rationale:

Telling the client that the surgeon will explain the procedure in the operating room is inappropriate. The client's concerns should be addressed promptly, and the explanation should occur before the surgery, allowing the client to make an informed decision. Operating rooms are not the appropriate setting for obtaining informed consent.

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Correct Answer is B

Explanation

Choice B rationale:

The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.

Choice A rationale:

Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.

Choice C rationale:

Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.

Choice D rationale:

Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.

A. Transparent dressing. B. Alginate dressing. C. Hydrogel dressing. D. Wet-to-dry gauze dressing.

Correct Answer is A

Explanation

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

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A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Correct Answer is B

Explanation

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Correct Answer is A

Explanation

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?