Nokea
A client is being admitted to a same-day surgery center for an exploratory laparotomy procedure. The surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that:
- A. The client understands the procedure
- B. The signature on the preoperative consent form is the client's
- C. The procedure has been explained
- D. The client is aware of potential complications
Correct Answer: B
Rationale: The correct answer is B because as a witness, the nurse's primary responsibility is to confirm that the signature on the preoperative consent form belongs to the client. The nurse is not confirming the client's understanding of the procedure (Choice A), but rather the authenticity of the signature. Choice C is incorrect because the nurse is not responsible for verifying that the procedure has been explained, but rather confirming the client's signature. Similarly, Choice D is incorrect because the nurse's role as a witness is not to ensure the client is aware of potential complications, but to verify the signature.
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The healthcare provider is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD). Which assessment finding would be most concerning?
- A. Barrel chest
- B. Clubbing of the fingers
- C. Cough with sputum production
- D. Use of accessory muscles
Correct Answer: D
Rationale: The use of accessory muscles is the most concerning finding in a client with COPD. It indicates increased work of breathing and may signal respiratory distress, requiring immediate attention. Barrel chest is a common physical characteristic in individuals with COPD due to chronic air trapping and hyperinflation of the lungs but is not as acutely concerning as the use of accessory muscles. Clubbing of the fingers is a late sign of chronic hypoxia and is often seen in conditions with prolonged hypoxemia but is not as acute as the use of accessory muscles. Cough with sputum production is a common symptom in COPD due to excess mucus production but does not indicate immediate respiratory distress as the use of accessory muscles does.
A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?
- A. Where the client ate his breakfast
- B. The times for routine vital sign measurements
- C. The exact times the client had visitors
- D. The type of transmission-based precautions in place
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- A. Loosen the right wrist restraint.
- B. Apply a pulse oximeter to the right hand.
- C. Compare hand color bilaterally.
- D. Palpate the right radial pulse.
Correct Answer: A
Rationale: The correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (Choice B) or palpating the right radial pulse (Choice D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (Choice C) is important but not the immediate action needed when a circulation issue is noted in one hand.
A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client's medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct Answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?
- A. I will keep my oxygen tank upright at all times.
- B. I will not use petroleum jelly to keep my nose from drying out.
- C. I will not smoke or allow others to smoke around me.
- D. I will call my doctor if I have difficulty breathing.
Correct Answer: B
Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.