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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Libel refers to written defamation of character. It does not apply to this situation as there are no written statements involved that defame the client.

Choice B reason: Assault involves creating a fear of imminent harmful or offensive contact. In this scenario, the nurse's action of having security apply restraints could be seen as creating an apprehension of physical harm, thereby constituting assault.

Choice C reason: False imprisonment occurs when a person is confined or restrained against their will without legal justification. Applying physical restraints to a competent client who wishes to leave the hospital can be considered false imprisonment.

Choice D reason: Slander refers to spoken defamation of character. Since this situation does not involve spoken statements that defame the client, slander is not applicable.

Choice E reason: Battery involves actual physical contact that is harmful or offensive. Having security apply physical restraints to the client constitutes battery, as it involves unwanted and offensive physical contact.

A. Client reports having intermittent mild headaches. B. Client reports some erectile dysfunction. C. Client reports having dyspnea and chest pain. D. Client reports having elevated liver function tests.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E"]

Explanation

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

A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

The nurse educator is reviewing the role of a nurse advocate with a group of newly hired nurses to the hospital. Which of the following statements indicate the newly hired nurses understand the roles of a nurse advocate? (Select All That Apply)

The nurse is caring for clients in the intensive care unit (ICU). Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Ms. Jones in room 312 doing?" Which response by the nurse would be most appropriate?

A charge nurse notes that a staff nurse delegates a large number of tasks to the assistive personnel (AP). The nurses on the next shift also report that the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

The nurse is assessing a client with a diagnosis of acute emphysema. The client is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which assessment findings should be reported to the provider immediately?

The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?