A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

Ask the surgeon to discuss the procedure with the client.

Explain the procedure in detail to the client.

Encourage the client to reread the consent form before signing.

Tell the client that the surgeon will explain it to him in the operating room.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

It's essential to ensure that the client fully understands the surgical procedure and its implications before signing the informed consent form. If the client expresses confusion or lack of understanding, the nurse should involve the surgeon to address the concerns directly. The surgeon is the most appropriate person to provide comprehensive information about the procedure, potential risks, benefits, and alternatives. This promotes patient autonomy and informed decision-making, aligning with ethical principles.

Choice B rationale:

While educating the client about the procedure is important, it's not the nurse's role to provide detailed explanations of surgical procedures. Additionally, the surgeon possesses the necessary expertise to explain medical procedures accurately. Relying on the surgeon for this explanation maintains professional boundaries and ensures accurate information dissemination.

Choice C rationale:

Encouraging the client to reread the consent form is insufficient if the client did not initially understand the explanation. The consent form might contain complex medical language, and the client might need direct communication with the surgeon to address specific concerns. Merely re-reading the form might not alleviate the client's confusion.

Choice D rationale:

Telling the client that the surgeon will explain the procedure in the operating room is inappropriate. The client's concerns should be addressed promptly, and the explanation should occur before the surgery, allowing the client to make an informed decision. Operating rooms are not the appropriate setting for obtaining informed consent.

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Correct Answer is D

Explanation

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

A. Left fourth intercostal space at the sternal border. B. Left third intercostal space at the sternal border. C. Left second intercostal space at the midclavicular line. D. Left fifth intercostal space at the midclavicular line.

Correct Answer is D

Explanation

The correct answer is: d. Left fifth intercostal space at the midclavicular line.

Choice A: Left fourth intercostal space at the sternal border

The fourth intercostal space at the sternal border is not the typical location for the Point of Maximal Impulse (PMI). This area is more commonly associated with the tricuspid valve auscultation point. The PMI is usually found more laterally and inferiorly.

Choice B: Left third intercostal space at the sternal border

The third intercostal space at the sternal border is also not the correct location for the PMI. This area is generally used for auscultating the pulmonic valve. The PMI is located further down and towards the midclavicular line.

Choice C: Left second intercostal space at the midclavicular line

The second intercostal space at the midclavicular line is typically where the aortic valve is auscultated. The PMI is not found this high up on the chest.

Choice D: Left fifth intercostal space at the midclavicular line

This is the correct location for palpating the Point of Maximal Impulse (PMI). The PMI is usually located at the apex of the heart, which is found at the left fifth intercostal space along the midclavicular line. This is where the left ventricle is closest to the chest wall and can be felt most strongly during systole.

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A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Correct Answer is D

Explanation

A nurse is performing a cardiovascular assessment on a healthy client. In which of the following anatomical landmarks would the nurse expect to palpate the client's Point of Maximal Impulse (PMI)?

Correct Answer is D

Explanation

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