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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Store unused patches in the refrigerator." Scopolamine patches should be stored at room temperature, not in the refrigerator.
B. "Apply the patch prior to traveling." The patch should be applied at least four hours before travel to allow time for absorption and effectiveness.
C. "Place the patch on your upper arm." The patch should be applied behind the ear, not on the upper arm, for optimal absorption.
D. "Replace a dislodged patch onto the same location." A new patch should be applied to a different area to prevent skin irritation.
Correct Answer is B
Explanation
A. Shaking insulin vials can cause bubbles and denature the insulin, especially NPH, which should be gently rolled between the hands to mix. Vigorous shaking can reduce effectiveness and increase the risk of inaccurate dosing.
B. Once regular and NPH insulin are drawn into the same syringe, the mixture should be administered promptly, ideally within 5 minutes, to maintain potency and prevent clumping. Delays can alter absorption and efficacy of the insulin.
C. The correct technique is to withdraw regular insulin first and then NPH, not the other way around. Drawing NPH first could contaminate the regular insulin vial with NPH, affecting rapid-acting insulin activity.
D. Air should be injected into each vial to equalize pressure before withdrawing the insulin, but the sequence should be air into NPH first, then air into regular insulin, to avoid contamination. Incorrect sequencing can introduce NPH into the regular insulin vial.
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