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A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?
- A. Obtain a court order for the surgery
- B. Sign the informed consent on behalf of the client
- C. Send the client to surgery without the consent form being signed
- D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers
Correct Answer: D
Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.
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The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?
- A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
- B. Give two rescue breaths
- C. Look, listen, and feel for breathing
- D. Begin chest compressions
Correct Answer: A
Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.
The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics
- B. Apply warm moist packs every two hours
- C. Elevate the right foot on two pillows
- D. Teach the client about skin and foot care
Correct Answer: A
Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.
An important part of nutrition therapy for patients with cystic fibrosis is:
- A. A low-fat diet to prevent steatorrhea
- B. A low-sodium diet to normalize fluid status
- C. A high-fiber diet to normalize bowel function
- D. Pancreatic enzyme replacement therapy to help digestion
Correct Answer: D
Rationale: The correct answer is D: Pancreatic enzyme replacement therapy to help digestion. In cystic fibrosis, pancreatic insufficiency leads to the malabsorption of nutrients, making it essential for patients to take pancreatic enzymes to aid in digestion. Options A, B, and C are incorrect because a low-fat diet may not provide adequate nutrition for cystic fibrosis patients, a low-sodium diet is not the primary focus of nutrition therapy in cystic fibrosis, and a high-fiber diet may exacerbate gastrointestinal symptoms due to malabsorption.
Patients with gallbladder disease should reduce their intake of:
- A. Protein
- B. Sodium
- C. Cholesterol
- D. Fat
Correct Answer: D
Rationale: Patients with gallbladder disease are advised to reduce their fat intake because fats can trigger gallbladder symptoms such as pain and bloating. While protein, sodium, and cholesterol may also impact overall health, reducing fat intake specifically helps manage gallbladder-related symptoms effectively. Protein is important for tissue repair, sodium can affect blood pressure, and cholesterol levels impact heart health, but in the context of gallbladder disease, fat reduction is the most beneficial.
Which vitamin deficiency is commonly associated with prolonged antibiotic use?
- A. Vitamin A
- B. Vitamin B6
- C. Vitamin C
- D. Vitamin K
Correct Answer: D
Rationale: The correct answer is Vitamin K. Prolonged antibiotic use can disrupt the gut flora, leading to Vitamin K deficiency and an increased risk of bleeding. Vitamin A deficiency is not commonly associated with antibiotic use. Similarly, Vitamin B6 and Vitamin C deficiencies are not typically linked to prolonged antibiotic use.