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When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. What action should be taken by the nurse? What criterion of informed consent has not been met in this situation?
- A. Inform the surgeon immediately.
- B. Document the patient's statement.
- C. Administer the medication as ordered.
- D. Delay medication until the surgeon clarifies.
Correct Answer: A
Rationale: Informed consent requires that the patient understands the procedure, which hasn't been met here.
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What best evaluates Mrs. West’s situation with wound separation and purulent drainage?
- A. This response is consistent with the inflammatory process
- B. Some drainage is to be expected from a surgical incision
- C. This response indicates a break in sterile technique has occurred
- D. This wound is healing by first intention
Correct Answer: A
Rationale: Inflammatory signs suggest infection, requiring further evaluation and treatment.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway.
- B. Call for help.
- C. Establish that the client is unresponsive.
- D. See if anyone saw the client fall.
Correct Answer: C
Rationale: Checking responsiveness is the first step in assessing the situation.
Which traits are clients with anorexia nervosa noted to have?
- A. Low self-esteem
- B. High self-esteem
- C. Perfectionism
- D. Intense desire to displease others
Correct Answer: C
Rationale: Perfectionism is a common trait among individuals with anorexia nervosa, driving their pursuit of unrealistic body ideals.
What nursing measure would be most helpful in obtaining Mr. Smith’s compliance with treatment?
- A. Involve Mrs. Smith in the teaching sessions
- B. Teach Mr. Smith about his prescribed medications
- C. Ask the social worker to talk to Mr. Smith
- D. Refer the Smiths to the American Lung Association
Correct Answer: B
Rationale: Education empowers patients to understand and adhere to their treatment plans.
What is the most common cause of orbital cellulitis?
- A. Sinus infection
- B. Trauma
- C. Foreign body
- D. All of the above
Correct Answer: A
Rationale: Sinus infections are the most frequent source of orbital cellulitis due to proximity and anatomical connections.