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 A
Explanation
Keep your environment well ventilated. This can help reduce nausea and vomiting by eliminating odors that might trigger them.
Some additional explanations are:
Choice B is wrong because eating three large meals each day can increase nausea and vomiting by overloading the stomach. It is better to eat small, frequent meals and avoid spicy, greasy, or strong-smelling foods.
Choice C is wrong because restricting intake of high-carbohydrate foods can lead to ketosis, which can worsen nausea and vomiting. High-carbohydrate foods can also help settle the stomach and provide energy.
Choice D is wrong because brushing your teeth immediately after eating can stimulate the gag reflex and cause nausea and vomiting. It is better to rinse your mouth with water or mouthwash after eating and brush your teeth at least an hour later.
Normal ranges for nausea and vomiting in pregnancy are:
- Nausea and vomiting usually start around 6 weeks of gestation and peak around 9 weeks. They usually subside by 16 to 20 weeks, but some women may experience them throughout pregnancy.
- Nausea and vomiting are considered mild if they do not interfere with daily activities or nutrition. They are considered moderate if they cause some difficulty with daily activities or nutrition. They are considered severe if they prevent adequate intake of fluids and nutrients, cause weight loss, dehydration, electrolyte imbalance, or ketonuria.
- Nausea and vomiting that are severe or persist beyond 20 weeks of gestation may indicate a complication such as hyperemesis gravidarum, molar pregnancy, multiple gestation, or infection.
Correct Answer is A
Explanation
Face the client at eye level when communicating.
This is because eye contact helps to establish rapport and trust with the client who has dementia and shows respect and attention. Facing the client at eye level also reduces distractions and background noise that might interfere with communication.
Choice B is wrong because offering correction of incorrect client statements can increase confusion, frustration, and agitation in the client who has dementia. Instead of correcting the client, the nurse should acknowledge their feelings and try to understand their perspective.
Choice C is wrong because reorienting the client to date and time with each encounter can be stressful and ineffective for the client who has dementia. Reorientation may work in the early stages of dementia, but as the disease progresses, the client may lose their ability to retain new information and may become more disoriented. Instead of reorienting the client, the nurse should use orienting names or labels whenever possible, such as “Your son, Jack” .
Choice D is wrong because avoiding using gestures when communicating with the client who has dementia can limit the nurse’s ability to convey meaning and emotion. Gestures can help to supplement verbal communication and provide cues for the client who has difficulty understanding words. However, the nurse should avoid using gestures that might be misinterpreted or threatening to the client, such as pointing or waving .
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