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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tying restraints to the side rail is unsafe and increases the risk of injury. Restraints should be attached to the bed frame, not the side rails.
Choice B rationale:
Removing the restraints every 3 hr is not enough to prevent complications such as skin breakdown, nerve damage, or circulation impairment.
Choice C rationale:
Securing restraints with a square knot can make it difficult to release them quickly in an emergency.
Choice D rationale:
Removing one restraint at a time allows the nurse to assess the client's behavior and readiness for restraint removal, as well as to provide care and comfort.
Correct Answer is A
Explanation
Choice A rationale:
Tuberculosis is transmitted via airborne droplets, so airborne precautions are necessary. The nurse should wear an N95 respirator mask when caring for the client, and the client should be placed in a negative pressure room. Airborne precautions include wearing a respirator mask, placing the client in a negative pressure room, and limiting the movement of the client outside the room.
Choice B rationale:
Droplet precautions are used for infections that are spread by large respiratory droplets, such as influenza or pertussis.
Choice C rationale:
Contact precautions are used for infections that are spread by direct or indirect contact with the client or their environment, such as scabies or Clostridium difficile.
Choice D rationale:
Protective precautions are used for clients who are immunocompromised and at risk of infection from others, such as those who have had a stem cell transplant or chemotherapy.
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