Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure.
Which of the following actions should the nurse take?
A. Send the unsigned informed consent form to the facility’s risk manager.
wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.
B. Ensure that the client’s family supports the provider’s decision for surgery.
wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate. The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.
C. Determine if the procedure is medically necessary for the client.
wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.
D. Determine if the client’s health care surrogate is aware of the risks and benefits of the procedure.
The correct answer is choice D. The nurse should determine if the client’s health care surrogate is aware of the risks and benefits of the procedure. A health care surrogate is a person who is authorized to make health care decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.
E. undefined
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice D. The nurse should determine if the client’s health care surrogate is aware of the risks and benefits of the procedure. A health care surrogate is a person who is authorized to make health care decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.
Choice A is wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.
Choice B is wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate.
The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.
Choice C is wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.
The provider is responsible for determining the medical necessity of the surgery and explaining it to the surrogate. The nurse should not question or interfere with the provider’s judgment unless there is evidence of negligence or malpractice.
Similar Questions
A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I can apply heat for the first 24 hours to minimize the pain in my hand.”
Applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.
B. “I should not use my affected hand for 4 to 6 weeks.”
The client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.
C. “I should expect numbness and tingling in my hand.”
Numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.
D. “I will need to keep my hand elevated above my heart for several days.”
“I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery. Elevation promotes venous return and prevents fluid accumulation in the tissues.
Full Explanation
I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery.
Elevation promotes venous return and prevents fluid accumulation in the tissues.
Choice A is wrong because applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.
Choice B is wrong because the client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.
Choice C is wrong because numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.
The client should expect these symptoms to improve or resolve after surgery, not persist or worsen. If the client experiences numbness and tingling after surgery, they should report it to the surgeon as it may indicate a complication such as nerve injury or hematoma.
Normal ranges for grip strength, pinch strength, and keypinch strength vary depending on age, sex, and hand dominance. However, a general reference for grip strength is 20 to 40 kg for men and 15 to 30 kg for women. For pinch strength, it is 6 to 12 kg for men and 5 to 10 kg for women. For keypinch strength, it is 4 to 8 kg for men and 3 to 7 kg for women.
These values may be lower in older adults or people with chronic conditions.
The client should expect some loss of strength in the affected hand after surgery, but it should gradually improve with rehabilitation.
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization.
The nurse observes blood on the child’s dressing.
A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.
B. Apply direct pressure to the puncture site.
Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.
C. Elevate the affected extremity above the level of the heart.
Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.
D. Leave the dressing undisturbed and notify the physician immediately.
Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.
Full Explanation
The correct answer is choice B. Apply direct pressure to the puncture site.
Choice A rationale:
Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.
Choice B rationale:
Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.
Choice C rationale:
Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.
Choice D rationale:
Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.
A nurse is caring for a 2-month-old infant who has heart failure.
Which of the following actions should the nurse take?
A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
B. Weigh the infant every other day.
is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
C. Place the infant in the prone position for naps.
wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
D. Check the infant’s oxygen saturation every 6 hr.
wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
E. undefined
Full Explanation
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.