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 ["A","B","C","D","E"]

Explanation

Choice A reason: Including client information on the disaster tag is crucial for identification and tracking purposes. This information ensures that each client can be accurately identified, which is essential for providing appropriate care and for communication with family members and other healthcare providers.

Choice B reason: Triage priority is an essential piece of information that indicates the level of urgency for each client's care. This prioritization helps healthcare providers quickly identify which clients need immediate attention and which can wait, thereby optimizing the use of limited resources during a mass casualty incident.

Choice C reason: Next of kin information is important for contacting family members and loved ones in case of emergency. This information is essential for communicating the client's status, obtaining additional medical history, and providing support to the family during a stressful time.

Choice D reason: Decontamination information, if applicable, indicates whether the client has undergone decontamination procedures. This is critical for ensuring that contaminated clients do not pose a risk to others, including healthcare providers and other patients, and for maintaining a safe environment within the healthcare facility.

Choice E reason: Documenting medications and treatments administered is vital for continuity of care. This information allows healthcare providers to track what treatments have been given, avoid duplication of medications, and monitor the client's response to treatment. It also ensures that any subsequent healthcare providers have a complete record of the client's care.

A. Slander B. Malpractice C. Battery D. Negligence

Correct Answer is D

Explanation

Choice A reason: Slander refers to spoken defamation of a person's character. Since this situation does not involve any spoken statements that defame the client, slander is not applicable.

Choice B reason: Malpractice is a specific type of negligence that occurs when a healthcare professional fails to perform their duties to the required standard, resulting in harm to a patient. While closely related, in this scenario, the broader term negligence more accurately describes the failure to follow hospital policy.

Choice C reason: Battery involves intentional and wrongful physical contact with a person without their consent, causing harm. In this situation, the nurse's failure to prevent the fall is not an intentional act, so battery is not applicable.

Choice D reason: Negligence occurs when someone fails to take reasonable care to avoid causing injury or loss to another person. In this case, the nurse's failure to initiate fall risk prevention measures, as required by hospital policy, resulted in the client falling and sustaining a wrist fracture, making the nurse at risk for negligence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

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

Explanation

Correct Answer is D

Explanation

The nurse manager of the emergency department arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?

A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

The nurse is on her break in the hospital cafeteria when she overhears two nurses talking about a client's condition. The nurse understands this could lead to which of the following complaints?

A nurse is completing the admission process for an older adult client new to the unit. After gathering the assessment data and reviewing the health history, which of the following best promotes client safety?

The nurse is caring for a client being prepared for a left total knee replacement surgery. The nurse is witnessing the surgeon obtain informed consent before the procedure. Which essential components must be present to obtain informed consent? (Select all that apply)

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?