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?

Notify the provider.

Describe the surgery to the client.

Provide brochures about the procedure.

Complete an incident report.

Answer and Explanation

The Correct Answer is A

Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason:
Supplemental oxygen supplies are correct. Seizures can sometimes cause a decrease in oxygen levels, so having supplemental oxygen available can help support the client's respiratory needs.
Choice B reason:
Limb restraints are incorrect. Limb restraints are not typically used for seizure precautions as they can be dangerous and restrict the client's movement, potentially causing harm during a seizure.
Choice C reason:
Oral suction equipment is correct. Seizures can be associated with excessive saliva or potential vomiting, so having oral suction equipment ready can help clear the airway if necessary.
Choice D reason:
The oral airway is incorrect. Inserting an oral airway is not a standard part of seizure precautions and should only be used by healthcare professionals with proper training.
Choice E reason:
The blood glucose monitor is correct. Monitoring blood glucose levels can be important, especially if the client takes antiepileptic medications that may affect blood sugar levels.

A. Attach the drainage bag to the side rails of the bed. B. Empty the drainage bag when it is three-quarters full. C. Tape the catheter to the lower abdomen. D. Keep the drainage bag below the level of the bladder.

Correct Answer is D

Explanation

Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider?

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)