The nurse is asked to witness surgical consent forms were obtained for clients, in the preoperative holding area. What client would not be able to consent legally to surgery?

The 22-year-old client who does not understand English

The 17-year-old client who has two fractured wrists

The 65-year-old client who cannot read or write

The 80-year-old client who is not oriented to the day

Answer and Explanation

The Correct Answer is D

A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.

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Correct Answer is B

Explanation

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

A. Level of consciousness B. Condition of drains C. Appearance of the surgical dressing D. Stability of vital signs

Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

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The nurse is asked to witness surgical consent forms were obtained for clients, in the preoperative holding area. What client would not be able to consent legally to surgery?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Correct Answer is B

Explanation

After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

Correct Answer is D

Explanation

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