The nurse is preparing a client for surgery and notices that the signed consent form has an error. The form states that the client is to have the left leg amputated. However, the client's right leg is marked for the surgery. The nurse administered the preoperative opioid medication 10 minutes ago and there are no family members present. Which action should the nurse implement?

Call the nearest relative to come in and sign a new form.

Call the healthcare provider (HCP) to have the procedure rescheduled.

Have the client sign another form before surgery.

Cross out the error and initial the consent form.

Answer and Explanation

The Correct Answer is B

A. Call the nearest relative to come in and sign a new form is not the correct course of action. While family involvement may be important, the priority is to address the error in the consent form before proceeding with the surgery. The healthcare provider must be informed to ensure the correct procedure is performed.

B. Call the healthcare provider (HCP) to have the procedure rescheduled is the most appropriate action. The error in the consent form and the discrepancy between the consent and the surgical site marking must be addressed immediately to prevent a potentially catastrophic mistake. The healthcare provider will need to correct the error and ensure proper documentation before proceeding with surgery.

C. Have the client sign another form before surgery is not appropriate because the client has already been administered opioid medication, which may impair their ability to make informed decisions. The error in the consent form must be resolved with the healthcare provider before the client signs anything.

D. Cross out the error and initial the consent form is not an appropriate action. This could be seen as tampering with the document, and it does not resolve the issue of the incorrect surgical site. A new consent form must be signed after the error is corrected.

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Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Ensure the client's environment is properly cleaned and disinfected. B. Reapply sterile non-adhesive dressing. C. Initiate contact precautions. D. Teach family members how to prevent transmission of infection.

Correct Answer is C

Explanation

A. Ensure the client's environment is properly cleaned and disinfected is important, but the priority action is to prevent the spread of MRSA, which is highly contagious. Contact precautions should be initiated immediately to reduce the risk of transmission to others, including healthcare staff and visitors.

B. Reapply sterile non-adhesive dressing is necessary for wound care, but it is not the most important action in this scenario. Ensuring the appropriate precautions are taken to prevent the spread of MRSA is the priority.

C. Initiate contact precautions is the most important action. MRSA is a highly contagious bacterial infection that can spread easily through contact with contaminated surfaces or individuals. By initiating contact precautions, the nurse helps to protect other patients, staff, and visitors from exposure to MRSA.

D. Teach family members how to prevent transmission of infection is important but should be done after the immediate infection control measures, such as initiating contact precautions, have been implemented. Family education can occur once the proper isolation procedures are in place.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

Correct Answer is C

Explanation

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)