A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

"Why are you changing your mind about the procedure?"

"This procedure is perfectly safe."

"I will contact the provider to let her know."

"You should discuss your concerns with your family!"

Answer and Explanation

The Correct Answer is C

A.   "Why are you changing your mind about the procedure?" This question may come across as confrontational or judgmental. It does not directly address the client’s need for information or support.
B.   "This procedure is perfectly safe." This response is dismissive and provides false reassurance. The nurse should avoid minimizing the client's concerns.
C.   "I will contact the provider to let her know." When a client expresses uncertainty about undergoing a procedure, the nurse's priority is to notify the provider. The provider is responsible for addressing the client’s concerns, clarifying the procedure, and ensuring informed consent. The client's autonomy must be respected, and they have the right to withdraw consent at any time.
D.   "You should discuss your concerns with your family!" While family support can be helpful, the decision to proceed or not is ultimately between the client and the provider. Directing the client to the family may undermine their autonomy.

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Correct Answer is ["A","B","C","D"]

Explanation

A. The medication administration record indicates the client received pain medication 12 hr ago. This is important to prevent overmedication and assess if the dosing schedule allows another administration.
B. The client reports a pain level of 7 on a scale from 0 to 10. Pain rating is a critical factor in deciding whether to administer PRN pain medication.
C. The client's pulse rate and blood pressure have decreased. Vital sign changes may indicate sedation or hemodynamic instability, which could contraindicate additional pain medication.
D. The client is restless and grimaces with movement. Nonverbal cues of pain are essential considerations, especially if the client is unable to communicate effectively.
E. The client's family tells the nurse the client is in pain. While family input can be valuable, pain assessment should be based on the client's report or nurse observations.

A. Inserting an indwelling urinary catheter B. Receiving moderate sedation C. Inserting a peripheral IV catheter D. Suctioning a tracheostomy tube E. Undergoing cardiac catheterization

Correct Answer is ["B","E"]

Explanation

A. Inserting an indwelling urinary catheter: This is a routine procedure that does not require informed consent.
B. Receiving moderate sedation: Moderate sedation involves the risk of respiratory depression and other complications, necessitating informed consent.
C. Inserting a peripheral IV catheter: Routine IV insertion does not require formal informed consent.
D. Suctioning a tracheostomy tube: Suctioning is a standard care procedure that does not require informed consent.
E. Undergoing cardiac catheterization: Cardiac catheterization is an invasive diagnostic or therapeutic procedure with potential risks, requiring informed consent.

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A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse consider before administering the prescribed PRN pain medication? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is ["B","E"]

Explanation

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