A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, “I cannot do this. I do not want this surgery.” Which of the following actions should the nurse take?

Tell the client about the benefits of the surgery.

Let the client know that their surgeon will be notified of their decision.

Reassure the client that it is expected to be nervous before surgery.

Inform the client that it is too late to stop the surgery.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Let the client know that their surgeon will be notified of their decision.

Choice A Reason:

Telling the client about the benefits of the surgery might seem helpful, but it does not address the client’s immediate concern. The client has expressed a clear decision to refuse the surgery, and the nurse must respect this decision by informing the surgeon. This approach aligns with the ethical principle of respecting patient autonomy.

Choice B Reason:

Letting the client know that their surgeon will be notified of their decision is the correct action. This respects the client’s autonomy and ensures that the surgeon is aware of the client’s wishes. It also allows for further discussion between the client and the surgeon, where the client can receive more detailed information and support.

Choice C Reason:

Reassuring the client that it is expected to be nervous before surgery is supportive but does not address the client’s refusal. While it is important to acknowledge the client’s feelings, the nurse must also take appropriate steps to respect the client’s decision and inform the surgeon.

Choice D Reason:

Informing the client that it is too late to stop the surgery is incorrect and unethical. Patients have the right to refuse treatment at any time, and it is the nurse’s duty to respect and facilitate this decision.

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Correct Answer is B

Explanation

Choice A Reason: Bounding Pulses

Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding.

Choice B Reason: Restlessness

Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention.

Choice C Reason: Warm Skin

Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding.

Choice D Reason: Brisk Capillary Refill

Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss. Therefore, brisk capillary refill is not indicative of active bleeding.

A. Increased heart rate during physical activity. B. Loss of appetite. C. Left lower extremity tenderness. D. Musculoskeletal weakness.

Correct Answer is C

Explanation

Choice A Reason

Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.

Choice B Reason

Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.

Choice C Reason

Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate intervention.

Choice D Reason

Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.

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A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, “I cannot do this. I do not want this surgery.” Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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