a nurse is preparing a client for surgery which of the following actions should be taken first

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse is preparing a client for surgery. Which of the following actions should be taken first?

A. Ensure informed consent is signed
B. Start IV fluids
C. Administer preoperative antibiotics
D. Reinforce surgical site dressing

Correct answer: A

Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.

2. Which action by a nurse demonstrates effective communication with a patient?

A. Providing the patient with written information about their care.
B. Maintaining eye contact and listening actively to the patient.
C. Using medical jargon to explain the patient's condition.
D. Speaking with the patient in a hurried manner to save time.

Correct answer: B

Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.

3. When providing discharge instructions for a patient with diabetes, what is the most important information to include?

A. Encourage the patient to maintain a high-carbohydrate diet.
B. Teach the patient how to monitor their blood sugar levels.
C. Recommend the patient engage in regular exercise.
D. Provide the patient with a list of restricted foods.

Correct answer: B

Rationale: The most critical information to include when providing discharge instructions for a patient with diabetes is teaching them how to monitor their blood sugar levels. This empowers the patient to actively manage their condition, make informed decisions about their diet and medication, and prevent complications. Encouraging a high-carbohydrate diet (Choice A) can be detrimental for diabetic patients as it may lead to unstable blood sugar levels. While regular exercise (Choice C) is important in diabetes management, monitoring blood sugar levels takes precedence. Providing a list of restricted foods (Choice D) is relevant but not as crucial as teaching the patient how to monitor their blood sugar levels.

4. What is the most appropriate method for assessing a patient's pain level?

A. Observe the patient's facial expressions.
B. Use a standardized pain scale, such as 0-10.
C. Ask the patient to rate their pain based on their mood.
D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

5. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?

A. Administer the medication as ordered.
B. Question the provider and verify the dose.
C. Administer half the dosage as a precaution.
D. Refuse to administer the medication without clarification.

Correct answer: B

Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.