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.

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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. Whether they contain pulp or fruit. B. The color and flavor of gelatin used. C. How many popsicles are available. D. If the popsicles are completely frozen.

Correct Answer is B

Explanation

A. Whether they contain pulp or fruit is unnecessary to assess because flavored gelatin is typically free of pulp or fruit. The concern lies more with the appropriateness of the ingredients as clear liquids.

B. The color and flavor of gelatin used is the correct response because some colored gelatins (e.g., red or purple) can mimic blood if vomiting occurs, potentially leading to misinterpretation of the child’s condition. The nurse should ensure that the parent uses neutral or light-colored gelatin (e.g., yellow or clear).

C. How many popsicles are available is not relevant to the appropriateness of the popsicles as a clear liquid or their potential effects on the child’s condition.

D. If the popsicles are completely frozen is not significant as long as the popsicles are made from appropriate clear liquids.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is B

Explanation

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

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

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?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

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?

The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurses implement to protect client privacy?

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?

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?