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 D
Explanation
Choice A rationale:
The client's age is not a part of the measurement in the Braden scale.
Choice B rationale:
Each element in the Braden scale has a range from one to four points, except for friction and shear, which is scored from one to three points.
Choice C rationale:
The lower the score, the higher the risk of developing pressure injuries.
Choice D rationale:
The Braden scale is a tool that helps nurses assess the risk of developing pressure injuries in clients. It consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Correct Answer is B
Explanation
Choice A rationale:
Nighttime urinary incontinence can occur in older adults but is not a universal finding.
Choice B rationale:
Decreased sense of balance is a common age-related change in older adults and can contribute to an increased risk of falls.
Choice C rationale:
Older adults may have a decreased, rather than heightened, sense of pain due to various factors.
Choice D rationale:
Increased nighttime sleeping is not a typical finding in older adults and can vary among individuals.
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