Nursing Elites

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?

• A. The client voluntarily grants permission for the procedure to be done
• B. The surgeon has explained to the client why the surgery is necessary
• C. The client is competent to sign the consent without impairment of judgment
• D. The client understands the risks and benefits associated with the procedure

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. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?

• A. Bulk-forming agent
• B. Antianxiety agent
• C. Stool softener
• D. Stimulant cathartic

Correct answer: C

Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.

3. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Observe the PICC line site for inflammation.
• B. Encourage increasing fluid intake.
• C. Monitor blood pressure regularly.
• D. Assess skin turgor for dehydration.

Correct answer: A

Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.

4. When washing soiled hands, what should the nurse do after wetting the hands and applying soap?

• A. Rub hands palm to palm
• B. Interlace the fingers
• C. Dry hands with a paper towel
• D. Turn off the water faucet

Correct answer: A

Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.

5. At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement?

• A. Administer insulin based on the sliding scale
• B. Assess the appearance of the foot wound
• C. Obtain antibiotic peak and trough levels
• D. Initiate hourly measurements of urine output

Correct answer: B

Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.

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