after the nurse witnesses a preoperative client sign the surgical consent form the nurse signs the form as a witness what are the legal implications o
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Nursing Elites

HESI LPN

HESI CAT Exam 2024

1. After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?

Correct answer: C

Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.

2. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?

Correct answer: D

Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.

3. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

4. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

Correct answer: A

Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.

5. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

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