A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?

The procedure can’t be canceled once the consent is signed.

It is in your best interest to have this surgery now.

Answer and Explanation

The Correct Answer is C

Answer and explanation

The correct answer is Choice C.

Choice A rationale

Procedures can be canceled even after consent. This statement disregards the client’s autonomy and right to change their decision regarding the planned surgery.

Choice B rationale

Encouraging immediate surgery does not respect the client’s doubts. This approach may undermine trust and does not address the client’s need for reassurance or clarification.

Choice C rationale

The surgeon is the most qualified to address the client’s concerns. Providing accurate, detailed explanations respects the client’s autonomy and supports informed decision-making about the surgery.

Choice D rationale

Nurses are not responsible for explaining surgical procedures. This explanation should be provided by the surgeon to ensure clarity, accuracy, and client understanding of the medical details.

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Correct Answer is B

Explanation

Choice A rationale

Dryness is not indicative of IV infiltration as this condition involves fluid leakage into surrounding tissue, typically leading to swelling, tenderness, or other abnormal signs at the site.

Choice B rationale

Edema is a common manifestation of IV infiltration caused by fluid leaking into interstitial spaces, leading to visible and palpable swelling, which may impair IV medication delivery and compromise tissue integrity.

Choice C rationale

Erythema often indicates inflammation or phlebitis, not infiltration, as infiltration usually causes pale, cool skin due to fluid collection in surrounding tissues rather than vascular irritation.

Choice D rationale

A distended vein is associated with venous congestion or occlusion rather than infiltration. Infiltration involves fluid leakage, leading to swelling and pallor, not vein distension or increased visibility.

A. Attach a probe carefully to the client’s finger. B. Apply a sensor pad to the client’s forehead. C. Secure a probe to one of the client’s toes. D. Obtain a pulse oximetry reading using an alternative site.

Correct Answer is B

Explanation

Choice A rationale

Peripheral edema may impede accurate readings due to compromised capillary blood flow in fingers. Thickened toenails may further reduce sensor reliability, leading to errors in oxygen saturation measurement.

Choice B rationale

The forehead is ideal for pulse oximetry in patients with peripheral edema. It provides a reliable alternative site with consistent capillary blood flow and is unaffected by thickened nails or peripheral circulation issues.

Choice C rationale

Peripheral edema affects capillary blood flow in toes, and thickened toenails obstruct sensor attachment, leading to unreliable and inaccurate oxygen saturation readings for clinical assessment.

Choice D rationale

While alternative sites might be useful, the forehead offers a proven, optimal placement for reliable oxygen saturation readings in cases of peripheral edema and other extremity-related complications.

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A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Correct Answer is B

Explanation

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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