A preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) of being really frightened and unsure about undergoing the surgery. Which priority action should the PN take?
Encourage the client to continue with the scheduled surgery.
Notify the charge nurse of the client's concerns about surgery.
Document that the client has expressed concerns about the surgery.
Remind the client that the consent has already been obtained.
The Correct Answer is B
A. Encouraging the client to proceed with the surgery may dismiss their valid fears and does not address the underlying emotional concerns. It is important to acknowledge the client’s feelings rather than pressuring them to continue.
B. Notifying the charge nurse of the client’s concerns ensures that the client’s emotional state and any potential issues with informed consent are addressed appropriately. The charge nurse can facilitate further discussion with the surgical team to ensure the client’s concerns are managed and that the consent remains valid.
C. Documenting the client’s concerns is important for legal and clinical reasons, but it does not address the client’s immediate emotional needs or resolve their fears. The priority is to ensure the client’s concerns are addressed and escalated if necessary.
D. Reminding the client that consent has already been obtained does not validate their current emotional concerns and can be dismissive. The focus should be on addressing the client’s anxiety and exploring their concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.
Correct Answer is D
Explanation
A. Determining if the spouse has medication allergies is unnecessary because the PN should not provide medication to anyone other than the patient. Medication administration policies are strict about who can receive medications and ensuring compliance with these policies is crucial for legal and safety reasons.
B. The PN cannot request medication for individuals who are not patients under their care, so this action does not follow hospital procedures. Medications must be administered through proper channels to ensure they are given safely and legally.
C. Giving medication from the nurse’s personal supply is a violation of hospital policy and professional ethics. All medications must be obtained through approved sources and administered according to prescribed orders for safety and legal reasons.
D. Explaining that medication can only be provided to clients ensures adherence to hospital policies and legal regulations. This action maintains professional boundaries and ensures that only those who are officially under care receive medication.
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