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.
Inform the client that it is too late to stop 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.
The Correct Answer is C
A. While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.
B. It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C. The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D. While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Denial is the first stage of grief, in which the person refuses to accept the reality of their situation and tries to maintain a sense of normalcy. The client who says they are looking forward to seeing their grandchildren grow up is denying the fact that they have a terminal illness and that they may not live long enough to witness that.
B. Bargaining involves making deals with self and God to help feel better, for instance, in this case the client will be expressing the will to do anything to prolong his life.
C. Acceptance involves coming to terms with the reality of the situation and preparing for death. The client's statement does not indicate full acceptance.
D. Anger involves feelings of resentment or frustration. The client's statement does not express anger towards their situation.
Correct Answer is ["A","C","E","F"]
Explanation
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
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