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A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Provide teaching about the surgical procedure for the client.

Instruct the client's spouse to sign the consent form.

Read the consent form to the client using words the client will understand.

Contact the provider who will be performing the procedure.

Answer and Explanation

The Correct Answer is D

Answer: D. Contact the provider who will be performing the procedure.

Rationale:

A) Provide teaching about the surgical procedure for the client:

While nurses play an essential role in patient education, it is the responsibility of the healthcare provider performing the procedure to ensure the patient fully understands the details, risks, and benefits. Nurses can clarify information but should not provide the initial comprehensive explanation of the procedure.

B) Instruct the client's spouse to sign the consent form:

The client is the one who needs to provide informed consent, not the spouse, unless the client is legally unable to do so. In such cases, legal documentation, such as a power of attorney, is required. Instructing the spouse to sign without proper authorization is inappropriate and potentially legally problematic.

C) Read the consent form to the client using words the client will understand:

While simplifying the language of the consent form can help, it is not sufficient if the client does not fully understand the procedure. Full understanding requires a detailed discussion about the procedure, risks, benefits, and alternatives, which should be done by the provider performing the procedure.

D) Contact the provider who will be performing the procedure:

The provider performing the procedure has the responsibility to ensure the client understands all aspects of the surgery. Contacting the provider to provide a thorough explanation ensures that the client receives accurate and complete information, allowing for truly informed consent.

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Correct Answer is B

Explanation

Let's break down the calculation:

Given:

Patient weight: 154 lbs
Enoxaparin dosage: 0.75 mg/kg
Available enoxaparin: 60 mg/0.6 mL

Step 1: Convert pounds to kilograms:

1 lb is approximately 0.4536 kg
So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)

Step 2: Calculate the total dose of enoxaparin:

Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg

Step 3: Determine the volume to administer:

We have enoxaparin 60 mg/0.6 mL
To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5mL.

Therefore, the nurse should administer 0.5mL of enoxaparin

A. INR 0.8, aPTT 85 seconds. B. INR 2, aPTT 60 seconds.

Correct Answer is B

Explanation

Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.

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A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

Correct Answer is B

Explanation

A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?

Correct Answer is B

Explanation

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