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 C

Explanation

A. Carry bedridden clients to safety by lifting them onto your back: This is not a safe or recommended practice for evacuating bedridden clients.
B. Ask ambulatory clients to help to move clients in wheelchairs: Ambulatory clients should be prioritized for independent evacuation rather than being assigned caregiving tasks.
C. Place dry towels around the bases of doors: This can help to prevent smoke from entering the room and provide some protection while awaiting rescue.
D. Aim the extinguisher at the top of the fire: The correct action is to aim the extinguisher at the base of the fire, where the fuel source is.

A. Weigh the client every other day. B. Place the client in a supine position. C. Encourage the client to ambulate three times per day. D. Report urine output less than 30 mL/hr.

Correct Answer is D

Explanation

A. Weigh the client every other day. Daily weights are essential for monitoring fluid retention in pulmonary edema.
B. Place the client in a supine position. The client should be placed in a high Fowler's position to improve lung expansion and reduce dyspnea.
C. Encourage the client to ambulate three times per day. Clients with pulmonary edema are often too compromised to ambulate frequently. Rest is initially preferred.
D. Report urine output less than 30 mL/hr. Low urine output may indicate decreased renal perfusion, fluid retention, or worsening heart failure, all of which require prompt reporting.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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