A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, "I don't know what my surgery tomorrow is for." Which of the following responses should the nurse make?
"I will make a note in your medical record that you don't understand the surgery."
"I will tell your provider that you have questions about the surgery."
"Would you like to hear about some other possible treatment options?"
"Would you like me to tell you more about the procedure?"
The Correct Answer is B
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.
Correct Answer is C
Explanation
A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.
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