A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has diarrhea and requests clear liquids for breakfast

A client who has a cast on the left leg and reports numbness and paresthesia

A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150

Answer and Explanation

The Correct Answer is C

Rationale:

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.

B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.

C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.

D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.

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

Explanation

Rationale:

A. Verify the client understands the surgical procedure ensures the client is making an informed decision based on a clear understanding of the procedure, risks, and benefits.

B. Validate the signature is authentic is crucial to confirm that the consent form is genuinely signed by the client, indicating their agreement to proceed.

C. Confirm that the consent is voluntary ensures that the client is not coerced into giving consent, upholding the principle of autonomy.

D. Explain the surgical procedure to the client is the responsibility of the surgeon or the provider, not the nurse. The nurse’s role is to witness the consent process and ensure that the client has been provided with and understands the information.

E. Establishing that the client is able to pay is not related to the informed consent process. Financial aspects are handled separately from the consent for treatment.

A. Keeping an appointment with a client B. Allowing a new mother to hold her stillborn infant C. Confirming that a client going for surgery has signed a consent form D. Refusing to disclose information about a client to the media

Correct Answer is A

Explanation

Rationale:

A. Keeping an appointment with a client demonstrates fidelity by honoring commitments and ensuring reliability in care.

B. Allowing a new mother to hold her stillborn infant is compassionate care but relates more to the ethical principle of beneficence.

C. Confirming that a client going for surgery has signed a consent form is related to the principle of autonomy and informed consent.

D. Refusing to disclose information about a client to the media is related to confidentiality, not fidelity.

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A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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Correct Answer is A

Explanation

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