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

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.

A. Nausea. B. Urine output of 40 mL/hr. C. Soft stools. D. Headache.

Correct Answer is A

Explanation

Choice A rationale

Nausea is a direct clinical manifestation of enteral feeding intolerance, often resulting from delayed gastric emptying or improper feeding rate, leading to gastrointestinal distress and potential aspiration risks.

Choice B rationale

A urine output of 40 mL/hr, while indicative of oliguria and potential renal compromise, is not associated with gastrointestinal intolerance to enteral feedings, as these involve different organ systems.

Choice C rationale

Soft stools are not a reliable indicator of feeding intolerance. They can occur due to dietary composition changes but are not associated with pathologic conditions needing intervention.

Choice D rationale

Headache is a nonspecific symptom that does not relate directly to feeding intolerance. Other causes, such as dehydration or systemic factors, are more likely culprits for this presentation.

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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 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

A nurse is monitoring a client who has been receiving intermittent enteral feedings. Which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?

A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?

A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?

A charge nurse is preparing a teaching session for a group of newly licensed nurses about the general principles of immunity. Which of the following statements should the nurse plan to include in the teaching?

A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse’s priority?

A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable?

A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?