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A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
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A nurse is caring for a client who is postoperative following a total knee replacement. The client reports numbness in the operative leg. Which of the following actions should the nurse take first?
- A. Administer a prescribed analgesic.
- B. Notify the provider of the numbness.
- C. Elevate the client's leg on pillows.
- D. Document the client's report in the medical record.
Correct Answer: B
Rationale: Notifying the provider of numbness is critical, as it may indicate a complication such as nerve damage or compartment syndrome, requiring immediate evaluation.
A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?
- A. Discovery phase
- B. Decision phase
- C. Trial phase
- D. Complaint phase
Correct Answer: A
Rationale: The correct answer is A: Discovery phase. During the discovery phase of a legal process, both parties exchange information and evidence relevant to the case. A deposition is a part of the discovery phase where witnesses are questioned under oath. In this scenario, the nurse manager would be required to participate in a deposition to provide information related to the lawsuit.
Option B: Decision phase is incorrect as it typically refers to the phase where a judgment or verdict is made. Option C: Trial phase is incorrect as it involves the actual court proceedings. Option D: Complaint phase is incorrect as it is the initial phase where a formal complaint is filed to initiate the legal process.
A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
- A. Do you know when I will be going home?
- B. My dressing was changed earlier this morning.
- C. I have not received any of my medications today.
- D. I do not know how to make the remote control work.
Correct Answer: C
Rationale: Correct Answer: C. "I have not received any of my medications today."
Rationale: This statement is concerning as it indicates a potential oversight in medication administration, which is crucial for postoperative clients. The nurse should follow up with the PN to ensure that the client receives the necessary medications promptly.
Summary of Other Choices:
A: Asking about discharge is appropriate and does not require immediate follow-up.
B: Reporting that the dressing was changed is a positive sign of wound care management.
D: Not knowing how to use the remote control is not a priority in postoperative care.
Overall, choice C stands out as it directly relates to the client's well-being and should be addressed promptly.
A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
- A. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
- B. The nurse uses clean gloves when discontinuing a client's intravenous infusion.
- C. The nurse uses the client's telephone number as one form of identification when administering medications to a client.
- D. The nurse empties a client's drainable colostomy pouch when it is one-third full.
Correct Answer: C
Rationale: The correct answer is C. Using a client's telephone number as identification is a violation of privacy and confidentiality. It is not a secure or reliable form of identification and could lead to errors in medication administration. The other choices do not indicate immediate intervention is needed. A: Opening the top flap of a sterile tray is incorrect but may not cause immediate harm. B: Using clean gloves for discontinuing an IV infusion is incorrect, but can be corrected easily. D: Emptying a colostomy pouch when it is one-third full is appropriate to prevent skin irritation and leakage.