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 B

Explanation

A. Compare muscle strength bilaterally is not the most immediate concern. Although muscle weakness is a potential sign of hypokalemia, the priority is assessing for cardiac complications, as potassium imbalances can cause life-threatening arrhythmias.

B. Determine apical heart rate and rhythm is the most important intervention. A potassium level of 2.5 mEq/L is dangerously low and can lead to life-threatening cardiac arrhythmias. The nurse should assess the heart rate and rhythm to detect any abnormalities such as bradycardia, tachycardia, or irregular rhythms, which are common in hypokalemia.

C. Observe color and amount of urine is not the priority. While renal function is important, the immediate concern in this case is the potential for severe cardiac complications due to the low potassium level.

D. Assess strength of deep tendon reflexes is important for detecting signs of hypokalemia, but it is secondary to assessing the heart, as potassium imbalances primarily affect cardiac function.

A. Complete an adverse occurrence/incident report. B. Ensure that the restraints are not too tight. C. Initiate the facility's restraint flow sheet. D. Demonstrate proper securing of the restraints.

Correct Answer is D

Explanation

A. Complete an adverse occurrence/incident report may be necessary if harm occurs, but the priority is to immediately correct the unsafe practice to prevent injury.

B. Ensure that the restraints are not too tight is important, but addressing the incorrect technique of securing restraints to the bedside rails takes precedence as it poses a greater risk to the client’s safety.

C. Initiate the facility's restraint flow sheet is part of documentation but does not address the immediate safety concern.

D. Demonstrate proper securing of the restraints is correct because restraints should never be secured to movable parts of the bed, such as the rails, as this can cause injury. The nurse must provide immediate education to the UAP to prevent harm and ensure the restraints are applied correctly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

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?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?