A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?
Place the client's ring in the facility safe.
Place the ring in the bag with the client's clothing
Tape the ring securely to the client's finger
Agree to keep the ring for the client until after surgery.
The Correct Answer is A
A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Accompanying a client to physical therapy is a task that can be appropriately delegated to an AP, as it does not require clinical judgment or advanced nursing knowledge. This task does not require the skills of an LPN.
B. Reinforcing dietary teaching with a client who has heart disease is within the scope of practice for an LPN. LPNs can reinforce teaching that has already been initiated by the registered nurse (RN). This task involves some level of knowledge and skill but does not require independent clinical judgment, making it suitable for the LPN.
C. Obtaining a urine specimen from an older adult client is a task that can be delegated to an AP, as it is a routine procedure that does not require nursing assessment or decision-making. This task does not require the skills of an LPN.
D. Providing postmortem care for a client who has just died is a task that can be appropriately delegated to an AP. This task involves following established protocols and does not require clinical judgment or advanced nursing skills. It is not necessary to assign this task to an LPN.
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
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