a client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics the nurse should take which b

ATI RN

ATI RN Custom Exams Set 2

1. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

A. Obtain a court order for the surgery
B. Sign the informed consent on behalf of the client
C. Send the client to surgery without the consent form being signed
D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.

2. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task 'Educate personnel on UCMJ'?

A. Accountability
B. Personal/professional development
C. Individual training
D. Military appearance/physical condition

Correct answer: B

Rationale: The correct answer is B: Personal/professional development. Educating personnel on UCMJ falls under the category of personal/professional development as it involves enhancing their understanding of the Uniform Code of Military Justice. This category focuses on improving individuals' knowledge and skills related to their professional roles and responsibilities. Choices A, C, and D are not directly related to educating personnel on UCMJ. Accountability pertains to being answerable for one's actions, individual training focuses on specific skill development, and military appearance/physical condition relates to grooming standards and fitness rather than UCMJ education.

3. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

A. Presence of thin pink drainage in the Jackson Pratt
B. Guarding when the nurse touches the abdomen
C. Tenderness around the surgical site during palpation
D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

4. What is the FIRST step in providing health care for a patient?

A. Obtain and interpret vital signs
B. Determine the needs of the patient
C. Develop a plan of care
D. Obtain lab work and x-rays

Correct answer: B

Rationale: The correct first step in providing health care for a patient is to determine the needs of the patient. Understanding the patient's requirements, concerns, and medical history is crucial before proceeding with any further steps. Option A, 'Obtain and interpret vital signs,' may be necessary but typically follows assessing the patient's needs. Option C, 'Develop a plan of care,' comes after identifying the patient's needs. Option D, 'Obtain lab work and x-rays,' is usually done based on the patient's needs and the developed plan of care, making it a later step in the process.

5. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

A. Explain to the client that it is too early to have an injection for pain
B. Call the practitioner, report the client’s symptoms, and obtain further orders
C. Reposition the client for greater comfort and turn on the television as a distraction
D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client’s symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.