A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)

The client has legal authority to do so.

The client does not have a mental health condition.

The client was not coerced.

The client signed in the nurse's presence.

The client speaks the same language as the nurse.

Answer and Explanation

Correct Answer : A,C,D

A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.

B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.

C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.

D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.

E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.

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Correct Answer is C

Explanation

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. B. The client who does not have a palpable thrill or auscultated bruit. C. The client who is reporting a 3.6 kg weight gain and it refusing dialysis. D. The client who has a hemoglobin of 9.0 mg/dL (12.0-15.5 mg/dL) and hematocrit of 26% (36.1% -44.3%).

Correct Answer is A

Explanation

A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.

B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.

C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.

D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.

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A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The absence of bowel sounds is established after listening for:

Correct Answer is C

Explanation

The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?

Correct Answer is A

Explanation

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