A preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) of being really frightened and unsure about undergoing the surgery. Which priority action should the PN take?
Encourage the client to continue with the scheduled surgery.
Notify the charge nurse of the client's concerns about surgery.
Document that the client has expressed concerns about the surgery.
Remind the client that the consent has already been obtained.
The Correct Answer is B
A. Encouraging the client to proceed with the surgery may dismiss their valid fears and does not address the underlying emotional concerns. It is important to acknowledge the client’s feelings rather than pressuring them to continue.
B. Notifying the charge nurse of the client’s concerns ensures that the client’s emotional state and any potential issues with informed consent are addressed appropriately. The charge nurse can facilitate further discussion with the surgical team to ensure the client’s concerns are managed and that the consent remains valid.
C. Documenting the client’s concerns is important for legal and clinical reasons, but it does not address the client’s immediate emotional needs or resolve their fears. The priority is to ensure the client’s concerns are addressed and escalated if necessary.
D. Reminding the client that consent has already been obtained does not validate their current emotional concerns and can be dismissive. The focus should be on addressing the client’s anxiety and exploring their concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Observing for signs of pain or discomfort during the treatment is not a direct method for evaluating ondansetron’s effectiveness. Ondansetron is used to prevent nausea and vomiting, not to manage pain.
B. While assessing vital signs is important for overall monitoring, it does not specifically measure the effectiveness of ondansetron for preventing nausea and vomiting.
C. Monitoring for nausea or vomiting following the treatment is the most direct way to evaluate the effectiveness of ondansetron. The primary goal of ondansetron is to prevent or reduce these symptoms associated with chemotherapy.
D. Evaluating if the client feels calm and relaxed is not a measure of ondansetron’s effectiveness. The focus should be on the medication’s ability to prevent nausea and vomiting rather than the client's emotional state before treatment.
Correct Answer is B
Explanation
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
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