The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

Have the client sign a new surgical permit.

Inform the surgeon about the client's concern.

Add the additional information to the permit.

Notify the surgical staff of the client's confusion.

Answer and Explanation

The Correct Answer is B

Choice A reason: Having the client sign a new surgical permit is not necessary unless the surgeon agrees to the addition of the procedure after being informed.

Choice B reason: The nurse should inform the surgeon about the client's request to include the removal of the second lipoma. The surgeon will decide if it is feasible and safe to add the procedure to the current surgical plan.

Choice C reason: The nurse cannot unilaterally add procedures to a surgical permit; this must be done by the surgeon after evaluating the client's condition and the risks involved.

Choice D reason: Notifying the surgical staff of the client's confusion does not address the client's request and may not lead to a resolution of the issue.

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Correct Answer is D

Explanation

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

A. Orient the client to their surroundings. B. Close the client's room door. C. Escort the client back to the room. D. Raise the four side rails on the bed. E. Secure a bed alarm on the mattress.

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

Explanation

Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.

Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.

Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.

Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.

Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.

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The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

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

Explanation

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