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 ["B","C","D","E","F"]

Explanation

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

A. Decline documenting the first counseling session. B. Communicate expected behavior to the AP. C. Explain to the AP the consequences of the behavior. D. Allow the AP time to respond to the counseling information. E. Conduct the counseling session with another AP present.

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

Explanation

A. Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B. Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C. Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D. Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E. Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.

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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 assisting in the care of a client. Exhibits The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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