A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

"The client works in the hospital radiology department."

"The client discussed having prior thoughts of suicide."

"The client's blood pressure and pulse have been fluctuating throughout the day."

"The client's family members have been present most of the day."

Answer and Explanation

The Correct Answer is C

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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Correct Answer is B

Explanation

Rationale:

A. "It is time to sign the consent so your treatment can begin." dismisses the client's valid question about alternative options and does not address their concern.

B. "Have you discussed other treatments with your provider?" is an appropriate response as it encourages the client to seek information about alternatives from their healthcare provider, who can offer comprehensive options and explanations.

C. "I can inform the surgeon you do not want the surgery." does not address the client's question about alternatives and assumes the client’s decision without further discussion.

D. "I would not have this type of surgery if I were you." is a personal opinion and is not appropriate for a nurse to provide, as it is not based on the client’s individual medical needs or informed consent principles.

A. Verify the client understands the surgical procedure. B. Validate the signature is authentic. C. Confirm that the consent is voluntary. D. Explain the surgical procedure to the client. E. Establish that the client is able to pay for the surgical procedure.

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

Explanation

Rationale:

A. Verify the client understands the surgical procedure ensures the client is making an informed decision based on a clear understanding of the procedure, risks, and benefits.

B. Validate the signature is authentic is crucial to confirm that the consent form is genuinely signed by the client, indicating their agreement to proceed.

C. Confirm that the consent is voluntary ensures that the client is not coerced into giving consent, upholding the principle of autonomy.

D. Explain the surgical procedure to the client is the responsibility of the surgeon or the provider, not the nurse. The nurse’s role is to witness the consent process and ensure that the client has been provided with and understands the information.

E. Establishing that the client is able to pay is not related to the informed consent process. Financial aspects are handled separately from the consent for treatment.

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A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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.)

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

Explanation

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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

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