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The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?
- A. Have the client sign a new surgical permit.
- B. Inform the surgeon about the client's concern.
- C. Add the additional information to the permit.
- D. Notify the surgical staff of the client's confusion.
Correct Answer: B
Rationale: Surgeon must evaluate and amend consent.
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When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
- A. Modify the nursing interventions to achieve the client's goals.
- B. Determine if the expected outcomes were realistic.
- C. Obtain current client data to compare with expected outcomes.
- D. Review related professional standards of care.
Correct Answer: C
Rationale: Current data assesses goal achievement.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?
- A. Fibromyalgia
- B. Peptic ulcer disease.
- C. Hypertension
- D. Hypothyroidism.
Correct Answer: C
Rationale: OSA increases blood pressure via hypoxia.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Offer positive reinforcement.
- B. Provide physical demonstrations.
- C. Use simulation activities.
- D. Incorporate verbal analogies.
Correct Answer: C
Rationale: Simulations enhance problem-solving skills.
The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.