The nurse is about to medicate a client who is to have surge...

The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?

A. Attempt to answer the client's questions
B. Notify the physician of the client's concerns prior to medicating the client
C. Reassure the client that the physician is well respected and very competent
D. Suggest that the client ask the physician her questions when in the operating room

Correct Answer: B

Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.

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The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.

A. I will apply moisturizing lotion on my legs every day.
B. I will elevate my legs at night when I am sleeping.
C. I will keep my legs below heart level when sitting.
D. I will start walking outside with my neighbor.
E. I will use a heating pad to promote circulation.

Correct Answer: A,C,D

Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.

The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.

A. Apply a water-soluble lubricating agent to moisturize mouth tissue
B. Avoid hot liquids and foods that are spicy or acidic
C. Brush your teeth with a soft-bristle toothbrush
D. Cleanse the mouth with saline after meals and at bedtime
E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor

Correct Answer: A,B,C,D

Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.

The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?

A. I will exhale a complete breath as quickly as possible through the mouthpiece of the device to obtain a peak flow reading
B. I will move the indicator to the desired reading on the numbered scale before using the device
C. I will record the lowest of 3 consecutive peak flow readings in my asthma journal every day.
D. I will remember to use the device after taking my fluticasone via metered-dose inhaler.

Correct Answer: A

Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.

At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should

A. Inform the client that she must wait until the program ends at 5:00 pm to leave
B. Give the client simple information about what she will be doing
C. Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
D. Firmly direct the client to her assigned group activity

Correct Answer: C

Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?

A. Act as a witness for the informed consent process
B. Reinforce information about what the client can expect
C. Report the surgeon to the ethics board for using an inappropriate consent process
D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter

Correct Answer: D

Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.