Nokea
A 15-year-old client needs life-saving emergency surgery, but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?
- A. Send the client to surgery without the consent.
- B. Call the family for a consent over the telephone and have another nurse listen as a witness.
- C. No action is necessary in this case because consent is not needed.
- D. Have the family sign the consent form as soon as they arrive.
Correct Answer: B
Rationale: For life-saving emergency surgery in a minor, telephone consent from the family with a witness is acceptable to meet legal requirements while expediting care.
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A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following stress interventions will be most helpful to the client?
- A. Review her current coping mechanisms and develop alternatives, if needed.
- B. Suggest a less stressful career in which she would still use her education and experience.
- C. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases.
- D. Prepare family members for the fact that she will have to work part-time.
Correct Answer: A
Rationale: Reviewing and developing coping mechanisms helps the client manage stress nbr without assuming drastic changes like altering her career or relying on others to adjust her workload. Preparing family for part-time work is premature and not directly stress-focused. CN: Psychosocial adaptation; CL: Synthesize
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
- A. Elevate the sequential compression device (SCD) on two pillows.
- B. Change the settings on the SCD to make the client more comfortable.
- C. Use the SCD to remove dressings and bathe the leg.
- D. Discontinue the SCD when the client is ambulatory.
Correct Answer: D
Rationale: The SCD is discontinued when the client is ambulatory, as mobility reduces the risk of thrombosis.
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
- A. Hematocrit.
- B. Partial thromboplastin time.
- C. Hemoglobin concentration.
- D. Prothrombin time.
Correct Answer: A
Rationale: Epoetin (Epogen) stimulates red blood cell production and is used to treat anemia. The nurse should assess hematocrit before administration to evaluate the client's response to therapy and ensure levels do not rise excessively, which can increase the risk of hypertension or thrombosis. Hemoglobin is also relevant but hematocrit is more commonly monitored. Coagulation times are not directly affected by epoetin.
The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:
- A. Check the dressing for signs of bleeding.
- B. Empty any peri-incisional drains.
- C. Assess the client's pain level.
- D. Assess the client's bladder.
Correct Answer: C
Rationale: After confirming airway and vital signs, assessing pain level is the next priority, as uncontrolled pain can affect recovery and complicate other assessments or interventions.