The nurse is preparing a client for surgery and notices that the signed consent form has an error. The form states that the client is to have the left leg amputated. However, the client's right leg is marked for the surgery. The nurse administered the preoperative opioid medication 10 minutes ago and there are no family members present. Which action should the nurse implement?

Call the nearest relative to come in and sign a new form.

Call the healthcare provider (HCP) to have the procedure rescheduled.

Have the client sign another form before surgery.

Cross out the error and initial the consent form.

Answer and Explanation

The Correct Answer is B

A. Call the nearest relative to come in and sign a new form is not the correct course of action. While family involvement may be important, the priority is to address the error in the consent form before proceeding with the surgery. The healthcare provider must be informed to ensure the correct procedure is performed.

B. Call the healthcare provider (HCP) to have the procedure rescheduled is the most appropriate action. The error in the consent form and the discrepancy between the consent and the surgical site marking must be addressed immediately to prevent a potentially catastrophic mistake. The healthcare provider will need to correct the error and ensure proper documentation before proceeding with surgery.

C. Have the client sign another form before surgery is not appropriate because the client has already been administered opioid medication, which may impair their ability to make informed decisions. The error in the consent form must be resolved with the healthcare provider before the client signs anything.

D. Cross out the error and initial the consent form is not an appropriate action. This could be seen as tampering with the document, and it does not resolve the issue of the incorrect surgical site. A new consent form must be signed after the error is corrected.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

A. Gives the client a hug and says, "It is okay to cry when you are sad." B. While touching the client's forearm, asks, "Would you like to talk about it?" C. "This is a bad time. I can see you are upset. I can come back later." D. "I am sorry to disturb you at a difficult time. This can wait until later."

Correct Answer is B

Explanation

A. Gives the client a hug and says, "It is okay to cry when you are sad" may seem comforting but could invade the client’s personal space and may not be appropriate in a professional setting without the client’s consent.

B. While touching the client's forearm, asks, "Would you like to talk about it?" is correct because it shows empathy, provides emotional support, and invites the client to share their feelings. The light touch conveys care without being intrusive.

C. "This is a bad time. I can see you are upset. I can come back later" dismisses the client’s emotional needs and prioritizes the nurse’s schedule over the client’s well-being.

D. "I am sorry to disturb you at a difficult time. This can wait until later" acknowledges the client’s emotions but does not provide immediate support or address their needs effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

Exhibits Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?