A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?
"I will make a note in your medical record that you don't understand the surgery."
"I will tell your provider that you have questions about the surgery."
"Would you like to hear about some other possible treatment options?"
"Would you like me to tell you more about the procedure?"
The Correct Answer is B
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
Correct Answer is E,C,D,A,B
Explanation
- Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
- Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
- Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
- Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
- Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.
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