A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?
Notify the provider.
Describe the surgery to the client.
Provide brochures about the procedure.
Complete an incident report.
The Correct Answer is A
Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason:
Supplemental oxygen supplies are correct. Seizures can sometimes cause a decrease in oxygen levels, so having supplemental oxygen available can help support the client's respiratory needs.
Choice B reason:
Limb restraints are incorrect. Limb restraints are not typically used for seizure precautions as they can be dangerous and restrict the client's movement, potentially causing harm during a seizure.
Choice C reason:
Oral suction equipment is correct. Seizures can be associated with excessive saliva or potential vomiting, so having oral suction equipment ready can help clear the airway if necessary.
Choice D reason:
The oral airway is incorrect. Inserting an oral airway is not a standard part of seizure precautions and should only be used by healthcare professionals with proper training.
Choice E reason:
The blood glucose monitor is correct. Monitoring blood glucose levels can be important, especially if the client takes antiepileptic medications that may affect blood sugar levels.
Correct Answer is C
Explanation
Choice A reason:
ALT is not primarily used to check kidney function. Kidney function is typically assessed through other tests, such as blood urea nitrogen (BUN) and creatinine levels.
Choice B reason:
ALT is not used to assess the risk of blood clots. It is specifically related to liver function.
Choice C reason:
Alanine aminotransferase (ALT) is an enzyme found primarily in the liver. An elevated ALT level in the blood can indicate potential liver damage or disease, so the ALT test is used to assess the function of the liver.
Choice D reason:
ALT is not a test to determine heart performance. Heart function is evaluated using tests such as electrocardiograms (ECGs) or cardiac enzymes.
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