A nurse is preparing a client for surgery and discovers a large sum of money in the client's wallet. Which of the following actions should the nurse take?

Contact security personnel to place the money in the designated secure location.

Label the money with the client's name and leave it at the nurses' station.

Place the money in an envelope in the client's medication drawer.

Hold the money for the client until their return from surgery.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Contact security personnel to place the money in the designated secure location: Hospitals have protocols for handling client valuables. The safest and most appropriate action is to notify security so the funds can be securely stored, documented, and returned appropriately. This maintains accountability and protects both the client and staff.

B. Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.

C. Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.

D. Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.

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Correct Answer is A

Explanation

Rationale:

A. "It expresses your wishes regarding health care when you can no longer communicate.": Advance directives are legal documents that state a client's preferences for medical care if they become unable to communicate those decisions themselves. This includes choices about life-sustaining treatments, resuscitation, and organ donation.

B. "It specifies your choices regarding funeral arrangements.": Funeral arrangements are typically addressed in a will or separate personal document, not in advance directives. Advance directives focus on medical decisions, not postmortem planning.

C. "It defines the criteria for the distribution of your assets.": The distribution of assets is handled through a last will and testament or estate planning documents, not through an advance directive. The directive is solely for healthcare-related decisions.

D. "It appoints a health care provider to speak for you with power of attorney for health care.": An advance directive may include the appointment of a health care proxy or agent, but it does not appoint a health care provider. It designates a trusted individual—not a clinician to make decisions if the client is incapacitated.

A. Decreased skin turgor B. Sensation of tingling C. Diminished capillary refill D. Pale-colored toes E. Pain relieved by analgesia

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

Explanation

Rationale:

A. Decreased skin turgor: Decreased skin turgor is a sign of dehydration or fluid imbalance and is not related to compartment syndrome. It does not reflect changes in perfusion or nerve compression caused by increased compartment pressure.

B. Sensation of tingling: Tingling or paresthesia is an early sign of nerve compression due to rising pressure within a muscle compartment. It indicates compromised nerve function and is a key symptom of evolving compartment syndrome.

C. Diminished capillary refill: Delayed or diminished capillary refill suggests impaired perfusion. In a newly placed cast, this can indicate increased pressure restricting blood flow—an early and critical sign of compartment syndrome.

D. Pale-colored toes: Pallor in the extremities is a sign of decreased arterial blood flow. Pale-colored toes after cast placement suggest compromised circulation, which is consistent with compartment syndrome.

E. Pain relieved by analgesia: Pain that is unrelieved by analgesia especially pain out of proportion to the injury is a hallmark of compartment syndrome. Pain that is relieved by medication does not indicate compartment syndrome and may reflect expected postoperative discomfort.

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A nurse is preparing a client for surgery and discovers a large sum of money in the client's wallet. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the purpose of advance directives with a client. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

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

Explanation

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