If a patient states that he is having second thoughts and is not sure he wants to have the surgery, the nurse would

ask his wife to speak to him to reassure him.

assure him that everything will go well.

tear up the surgical consent he signed.

notify the surgeon right away of the situation.

Answer and Explanation

The Correct Answer is D

A. Ask his wife to speak to him to reassure him.
This option is not ideal because the nurse should address the patient's concerns directly. It is important to ensure the patient is making an informed decision and is emotionally supported, but the spouse should not be the first point of contact for reassurance in this case.

B. Assure him that everything will go well.
While it is important to reassure the patient, the nurse should not make promises about the outcome. Assuring the patient everything will go well could lead to unrealistic expectations and may not address the underlying concern.

C. Tear up the surgical consent he signed.
Tearing up the consent is not an appropriate action. The nurse should not act on the patient's uncertainty before consulting the surgeon. The patient has the right to withdraw consent, and this should be addressed properly through communication with the surgeon.

D. Notify the surgeon right away of the situation.
The nurse should immediately notify the surgeon about the patient's change of mind. The surgeon is responsible for providing further clarification and addressing any concerns before proceeding with surgery. The patient must be fully informed and comfortable with their decision.

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Correct Answer is B

Explanation

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.

A. alternately compress and release to help blood flow through vessels. B. measure pressure in the leg blood vessels and sound an alarm if pressure rises. C. provide gentle continuous compression at low pressure. D. provide firm continuous compression at high pressure.

Correct Answer is A

Explanation

A. Alternately compress and release to help blood flow through vessels. Sequential compression devices (SCDs) work by alternating compression and release to promote venous return, prevent stasis, and reduce the risk of deep vein thrombosis (DVT). This is the correct mechanism of action for these devices.

B. Measure pressure in the leg blood vessels and sound an alarm if pressure rises. SCDs do not measure pressure; they are designed to apply intermittent pressure to the legs to encourage circulation and prevent clot formation.

C. Provide gentle continuous compression at low pressure. SCDs apply intermittent pressure, not continuous pressure. Continuous compression would not be effective in preventing DVT as it does not allow for the periodic relaxation of veins.

D. Provide firm continuous compression at high pressure. SCDs should apply intermittent, not continuous, pressure. High pressure could potentially harm the patient’s circulation and tissues, which is why the compression is designed to be gentle and alternating.

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If a patient states that he is having second thoughts and is not sure he wants to have the surgery, the nurse would

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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