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A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
- A. Witness the client signing the consent form.
- B. Evaluate that the client understands the procedure.
- C. Explain the risks of the procedure to the client.
- D. Verify that the client is signing the consent form of his own free will.
- E. Determine that the client understands postprocedure care.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.
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A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
The 'I Can Cope,' 'CanSurmount,' and 'Reach to Recovery' programs are all designed to help cancer clients:
- A. Choose treatment centers.
- B. Find financial help.
- C. Obtain home health care.
- D. Cope with cancer.
Correct Answer: D
Rationale: These programs are designed to provide emotional and practical support to help cancer clients cope with their diagnosis and treatment.
Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?
- A. Septic shock.
- B. Chronic obstructive pulmonary disease.
- C. Asthma.
- D. Heart failure.
Correct Answer: A
Rationale: Septic shock is a major ARDS risk factor due to systemic inflammation and lung injury. COPD, asthma, and heart failure are not primary ARDS triggers.
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?
- A. Encouraging the intake of cranberry juice.
- B. Advising the client to eat large amounts of cheese.
- C. Establishing regular times for elimination.
- D. Having the client dangle at the bedside.
Correct Answer: D
Rationale: Dangling at the bedside is inappropriate, as it risks cast damage and improper positioning.
A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following?
- A. Tachycardia.
- B. Weight gain.
- C. Diarrhea.
- D. Nausea.
Correct Answer: B
Rationale: Hypothyroidism causes a slowed metabolism, leading to weight gain. Tachycardia, diarrhea, and nausea are more associated with hyperthyroidism.