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A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
- A. Make sure the surgeon obtained the client's consent
- B. Witness the client's signature on the consent form
- C. Explain the risks and benefits of the procedure
- D. Describe the consequences of choosing not to have the surgery
- E. Tell the client about alternatives to having the surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: The nurse should ensure the surgeon obtained the client's consent as the surgeon is responsible for informing the client about the procedure and obtaining consent.
B: Witnessing the client's signature on the consent form ensures that the client signed voluntarily and with full understanding.
Summary:
C: While explaining risks and benefits is important, it is primarily the surgeon's responsibility.
D: Describing consequences of not having surgery is relevant but not directly related to obtaining informed consent.
E: Although discussing alternatives is crucial, it is not a direct part of the informed consent process.
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A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all.
- A. Take frequent sips of water
- B. Wear sunglasses when exposed to sunlight
- C. Use a soft toothbrush when brushing teeth
- D. Take the medication with an antacid
- E. Urinate prior to taking the medication
Correct Answer: A, B, E
Rationale: The correct choices for managing anticholinergic effects of oxybutynin are A, B, and E. A: Taking frequent sips of water helps combat dry mouth, a common anticholinergic effect. B: Wearing sunglasses when exposed to sunlight helps with sensitivity to light, another anticholinergic effect. E: Urinating prior to taking the medication helps reduce urinary retention, a potential side effect.
Incorrect choices: C: Using a soft toothbrush is not directly related to managing anticholinergic effects. D: Taking the medication with an antacid may interfere with its absorption and is not recommended.
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
- A. Eating more protein is optimal prior to testing
- B. One stool specimen is sufficient for testing
- C. A red color change indicates a positive test
- D. The specimen cannot be contaminated
Correct Answer: D
Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners. Choice A is incorrect because protein intake does not affect the test. Choice B is incorrect as multiple stool specimens are usually required. Choice C is incorrect as a blue color change indicates a positive test, not red.
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?
- A. A word she whispers 30cm from his ear
- B. A number she traces on the palm of his hand
- C. The vibration of a tuning fork she places on his foot
- D. A familiar object she places in his hand
Correct Answer: D
Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.
A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all.
- A. Most food poisoning is caused by a virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products
- D. Healthy individuals usually recover from the illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B, C, E
Rationale: The correct choices are B, C, and E. B is correct because immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning. C is correct because pasteurized dairy products are less likely to contain harmful bacteria that can cause food poisoning. E is correct because proper food handling, such as separating raw and fresh foods to prevent cross-contamination, can help reduce the risk of food poisoning. A is incorrect because most food poisoning is actually caused by bacteria, not viruses. D is incorrect because while healthy individuals may recover from food poisoning, the recovery time can vary and may not always be within a few weeks.