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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Related Questions
Correct Answer is D
Explanation
A. Keep the urinary bag at bladder level when ambulating. This is incorrect because the collection bag should always be kept below the bladder level to prevent backflow of urine, which can increase the risk of infection.
B. Loop the tubing so that it is lower than the collection bag. This is incorrect because kinking or looping the tubing can obstruct urine flow, leading to stasis and increasing the risk of bacterial growth and infection.
C. Obtain urinary samples by disconnecting the tubing connections. This is incorrect because disconnecting the system increases the risk of introducing bacteria. A sample should be obtained from the designated port using aseptic technique.
D. Secure the catheter to the client's thigh. This is correct because securing the catheter reduces movement and prevents urethral trauma, which lowers the risk of infection.
Correct Answer is D
Explanation
A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.
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