A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?
Delay the admission while the client fills out the facility’s advance directives form.
Confirm with the client’s family that the consent form has been signed.
Explain to the client that signing the facility’s consent form means they cannot refuse care.
Determine if the client has prepared their advance directives.
The Correct Answer is D
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Correct Answer is ["A","C"]
Explanation
Choice A reason:
The Bradley method teaches the labor partner how to coach and support the mother during labor. This is true because the Bradley method emphasizes the role of the partner as an active participant and a skilled coach who can help the mother relax, breathe, and cope with pain during labor. The partner also serves as an advocate for the mother's preferences and needs in the hospital setting.
Choice B reason:
The Bradley method teaches the mother and partner about the variety of methods to control pain. This is false because the Bradley method does not teach a variety of methods to control pain, but rather focuses on relaxation as the main way to reduce pain during labor. The Bradley method also discourages the use of medication or medical interventions for pain relief, unless they are medically necessary.
Choice C reason:
The Bradley method prepares the woman to deliver without medical interventions and medications. This is true because the Bradley method aims to help women have an unmedicated birth with minimal medical intervention. The Bradley method teaches women how to avoid unnecessary interventions and how to cope with natural labor by using relaxation, breathing, nutrition, and exercise. The Bradley method also educates women on how to reduce their risk of having a C-section and what to do if it becomes medically necessary.
Choice D reason:
The Bradley method focuses on muscle control because muscle tension increases the pain of labor. This is false because the Bradley method does not focus on muscle control, but rather on deep and complete relaxation during labor. The Bradley method believes that muscle tension interferes with the natural process of labor and increases pain, so it teaches women how to relax their muscles and let their bodies do the work.
Choice E reason:
The Bradley method is the most widely used method in the US. This is false because the Bradley method is not the most widely used method in the US, but rather one of several options for natural childbirth. According to a 2017 survey by Listening to Mothers, only 4% of women reported using the Bradley method for their most recent birth, compared to 48% who used Lamaze, 14% who used hypnobirthing, and 9% who used other methods.
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