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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Notify information services department of the situation is the correct first step. The nurse should immediately report the issue to the information services department to resolve the problem with the computer system. This ensures that the issue is addressed promptly and minimizes any delays in documentation or patient care.

B. Wait for notification that the system has been rebooted is not the best action. While waiting for the system to reboot might be necessary, the nurse should first notify the information services department to expedite the resolution of the issue.

C. Identify information as late entry in the record may be necessary once the system is restored, but the immediate priority is to report the system failure so that it can be addressed and the documentation can be completed correctly.

D. Print electronic medical record (EMR) from backup server may be an option if the system cannot be restored, but the first step should be to notify the information services department. The backup server can be used if needed after the issue is reported.

A. Administer a PRN sedative prescription. B. Leave the door to the client's room open slightly. C. Provide a back rub at bedtime. D. Apply wrist restraints to prevent wandering.

Correct Answer is C

Explanation

A. Administer a PRN sedative prescription should not be the first intervention. Non-pharmacological measures, such as promoting relaxation, should be attempted before resorting to medications.

B. Leave the door to the client's room open slightly can help with orientation but does not directly address the client's need for relaxation or sleep.

C. Provide a back rub at bedtime is a non-invasive, calming intervention that can help the client relax and promote sleep. It is appropriate to try this first before escalating to other measures.

D. Apply wrist restraints to prevent wandering is a last resort and should only be used when all other interventions have failed and the client poses a risk to themselves or others. Restraints are not indicated in this scenario without further justification.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

Correct Answer is A

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is C

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

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?

A client with atrial fibrillation receives a prescription for a loading dose of digoxin 0.5 mg PO. The medication is available in 125 mcg tablets. How many tablets should the nurse administer? (Enter numerical value only.)

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

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?

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)