A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?
"The client who had abdominal surgery 3 days ago is reporting feeling constipated.”
"The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.”
"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.”
"The client who is scheduled for discharge today states they are ready to sign their paperwork.”
The Correct Answer is C
Choice A rationale:
The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.
Choice B rationale:
The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.
Choice C rationale:
The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.
Choice D rationale:
The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Correct Answer is B
Explanation
The correct answer is choice B: "Ask the client to explain the procedure that is being performed."
Choice A rationale:
While verifying that the client understands the risks of the surgery (Choice A) is important, the question specifically asks about verifying informed consent. Informed consent involves ensuring that the patient comprehends the procedure being performed, its benefits, risks, and alternatives. While understanding the risks is a part of this, it's not the complete picture.
Choice B rationale:
The correct response is "Ask the client to explain the procedure that is being performed." This approach ensures that the client truly comprehends the procedure and its implications. If the client can accurately explain the procedure, it indicates a better understanding of what they are consenting to, which aligns with the concept of informed consent.
Choice C rationale:
Answering the client's questions about the outcomes of the surgery (Choice C) is important for providing education and addressing concerns, but it doesn't directly verify informed consent. The focus of informed consent is on the procedure itself, including its nature, purpose, and potential risks.
Choice D rationale:
Determining if the client understands the benefits of the procedure (Choice D) is only part of the informed consent process. While understanding the benefits is essential, it's equally important to ensure the client comprehends the risks and alternatives, which is better assessed by having the client explain the procedure.
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