The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?
a. Obtain informed consent from the client.
b. Continue teaching the client about the surgery.
c. Revise the teaching plan for the client.
d. Notify the surgeon and document the finding.
D
The surgeon should be notified right away so that the client can be instructed about the surgery to be performed. The client cannot give informed consent unless he or she understands the pro-cedure.
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A female patient has been taking isotretinoin
(Amnesteem) for 3 months. During a follow-up appointment, which statement by the patient would be of highest concern to the nurse? a. "I am using two forms of contraception while on this drug." b. "I have been feeling rather down and lonely lately." c. "I wish I didn't have to be on this medication." d. "It's scary to know that this drug can cause birth defects."
The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond?
1. "Your baby is taking a little longer than average, but is making progress." 2. "First babies take a long time to be born. The next baby will be easier." 3. "The birth would go faster if you had taken prenatal classes and practiced." 4. "Every baby is different; there really are no norms for labor and birth."
A 61-year-old client with diabetes mellitus has physician's orders for meticulous foot care. Which of the following is the best rationale for the order?
1. The aging process causes increased skin breakdown. 2. There is increased neuropathy with this pathology that places the client at risk. 3. The client probably has a history of poor hygienic care. 4. The lower extremities are difficult to see and therefore hard to maintain with good hygiene.
When using the tympanic thermometer for children under age 3, pull the pinna down and back
Indicate whether the statement is true or false