A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)
Explain the surgical procedure to the client.
Validate the signature is authentic.
Verify the client understands the surgical procedure.
Confirm that the consent is voluntary.
Establish that the client is able to pay for the surgical procedure.
Correct Answer : B,C,D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Thrombocytopenia (low platelet count) predisposes the client to spontaneous bleeding. This can manifest as petechiae (small red or purple spots on the skin), purpura (larger areas of purple discoloration), mucosal bleeding (such as nosebleeds or bleeding gums), or internal bleeding (such as gastrointestinal or intracranial bleeding). Monitoring for signs of bleeding is essential to promptly intervene and prevent complications.
B. While infections can occur in any client, a low platelet count does not directly predispose the client to infection. Thrombocytopenia primarily affects hemostasis rather than immune function.
C. Oliguria refers to decreased urine output, typically less than 400 mL/day in adults. It is not directly related to thrombocytopenia but may occur in conditions affecting kidney function or fluid balance.
D. Hyperactive deep tendon reflexes can indicate neurological conditions or electrolyte imbalances but are not associated with thrombocytopenia.
Correct Answer is B
Explanation
A. It is particularly sensitive to deficiencies in clotting factors, but it does not measure the deficiencies themselves
B. The activated partial thromboplastin time (aPTT) test measures the effectiveness of the intrinsic and common pathways of the coagulation cascade.
C. There is no need to skip breakfast or alter diet for an aPTT test. It is not affected by food intake or fasting status.
D. While aPTT is used to monitor heparin therapy, it is not typically used to monitor warfarin (a vitamin K antagonist) therapy. Warfarin therapy is usually monitored using the prothrombin time (PT) and international normalized ratio (INR) tests.
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