A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

Contact the client's power of attorney to sign the consent.

Inform a family member of the need to sign the consent.

Notify the surgical team that the client is unable to sign the consent.

Allow the client to sign the consent with an X

Answer and Explanation

The Correct Answer is D

Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.

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Correct Answer is A

Explanation

A high white blood cell (WBC) count is a common sign of infection and inflammation, such as pneumonia. The normal range of WBC count is 4,500 to 11,000/mm3 . Sodium, blood urea nitrogen (BUN), and hematocrit are not directly related to pneumonia and may vary depending on other factors such as hydration status, renal function, and blood loss.

A. "I will have to wait 2 months before additional saline can be added to my breast expander." B. "I should expect less than 25 mL of secretions per day in the drainage devices." C. "I will keep my left arm flexed at the elbow as much as possible." D. "I will perform strength-building arm exercises using a 15-pound weight."

Correct Answer is B

Explanation

The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.

The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.

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A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

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