A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?
Provide brochures about the procedure.
Notify the provider.
Describe the surgery to the client.
Complete an incident report
The Correct Answer is B
Choice A rationale:
Providing brochures about the procedure may be helpful, but the immediate concern is the client's expressed lack of understanding.
Choice B rationale:
Notifying the provider is the first action to address the client's concerns and ensure that the client has a clear understanding of the surgery. The nurse should also document the client's statement and the provider's response in the medical record.
Choice C rationale:
Describing the surgery to the client is important, but the provider should be informed first to address the client's immediate concerns.
Choice D rationale:
Completing an incident report is not applicable in this context, as it involves a communication issue rather than an incident.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using a cotton tip applicator to clean inside the inner cannula can cause cotton fibers to be dislodged and enter the trachea, posing a risk of aspiration.
Choice B rationale:
Cleansing the skin around the stoma with normal saline is an appropriate action for a client with a tracheostomy. This helps maintain skin integrity and prevent infection.
Choice C rationale:
Soaking the outer cannula in warm, soapy tap water is not a recommended practice. It may compromise the integrity of the tracheostomy equipment.
Choice D rationale:
Securing the tracheostomy ties to allow one finger to fit snugly underneath is a guideline for securing ties at the correct tightness to prevent complications. However, it is not a cleaning action.
Correct Answer is A
Explanation
Choice A rationale:
This will reduce splashing and aerosolization of the solution. This prevents contamination of the solution and the sterile field by keeping a safe distance from the bowl.
Choice B rationale:
Sterile gloves should be applied after the sterile field is established to prevent contamination. This will prevent contamination of the gloves by touching the outside of the bottle.
Choice C rationale:
the nurse should place the lid of the sterile solution bottle face up on a separate sterile drape, not face down on the same drape. This will prevent contamination of the lid and the drape by touching each other.
Choice D rationale:
the nurse should hold the bottle of sterile solution so that the label is facing away from the palm of the hand, not towards it. This will prevent the label from getting wet and unreadable.
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