Nursing Elites

1. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

• A. Telling the client that she needed to ask these questions before signing the informed consent for surgery
• B. Contacting the surgeon and requesting that she visit the client to answer her questions
• C. Informing the client that she has the right to cancel the surgical procedure if she wishes
• D. Telling the client that it is her surgeon's responsibility to explain the procedure

Correct answer: B

Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery. Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension. Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.

2. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?

• A. Open the airway.
• B. Administer oxygen.
• C. Suction the client.
• D. Check for breathing.

Correct answer: A

Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.

3. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?

• A. heart rate, respiratory effort, color, muscle tone, reflex irritability
• B. heart rate, bleeding, cyanosis, edema
• C. bleeding, reflex, edema
• D. respiratory effort, heart rate, seizures

Correct answer: B

Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.

4. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

• A. Ignoring the situation
• B. Documenting the problem in the nursing assistant's personnel file
• C. Asking other staff members to cover for the nursing assistant
• D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

5. Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?

• A. "I will make sure there is always an extra oxygen tank in your room."?
• B. "I will ask the previous nurse if the extra tank was needed."?
• C. "I will need to check if your insurance benefits would cover an additional oxygen tank."?
• D. "The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby."?

Correct answer: D

Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.

Similar Questions