The nurse is caring for a client on the medical-surgical unit who is scheduled for a right hip replacement surgery today. While completing the client assessment, the nurse notes the client has periods of intermittent confusion, sometimes forgetting where she is or why she is in the hospital. Consent for surgery has not yet been obtained. What is the priority action?

Reassess the client when the provider arrives to obtain the informed consent.

Notify the provider of the client's orientation.

Call the nursing supervisor to give consent for the surgery.

Ask another nurse to witness the informed consent.

Answer and Explanation

The Correct Answer is B

Choice A reason: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made.

Choice B reason: Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent.

Choice C reason: Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client.

Choice D reason: Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.

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Correct Answer is C

Explanation

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

A. Assist the visitor to the emergency department B. Take the visitor's blood pressure C. Encourage the visitor to lie down to see if the symptoms improve D. Advise the visitor to call their primary care provider

Correct Answer is A

Explanation

Choice A reason: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome.

Choice B reason: While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care.

Choice C reason: Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition.

Choice D reason: Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

Correct Answer is C

Explanation

The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?

Correct Answer is A

Explanation

The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

The nurse at an ambulatory care clinic is participating in an active shooter drill. The shooter is rapidly approaching the nurse's location and the nurse cannot get to an exit. What next best action is appropriate?

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select All That Apply)

The nurse working on the medical-surgical unit has delegated several patient care tasks to the unlicensed assistive personnel. What is the nurse's primary responsibility after the delegation of tasks?

The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?