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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Moist heat can help reduce pain and stiffness in the joints by increasing blood flow and relaxing the muscles. Moist heat can be applied using warm compresses, heating pads, or warm baths.

Choice A is wrong because using a recliner when sitting for long periods can increase pressure on the knees and decrease circulation. A better option is to use a straight-backed chair with a footstool.

Choice C is wrong because sleeping on a soft mattress can cause poor alignment of the spine and joints, which can worsen pain and mobility. A firm mattress is recommended for clients with osteoarthritis.

Choice D is wrong because placing large pillows under the knees when lying in bed can limit the range of motion of the knees and cause contractures. A small pillow under the knees can provide some support and comfort, but it should not be too large or too high.

A. Check the back of the throat with a pen light. B. Obtain the child’s vital signs in 15 min. C. Administer analgesia. D. Offer the child a drink of water.

Correct Answer is A

Explanation

A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.

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A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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