NR226/NR 226 Exam 4 V3 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing a client for an elective surgical procedure. Which action is most
appropriate when the client expresses a lack of understanding regarding the risks of the
surgery despite having signed the consent form?
A. Reassure the client that the surgical team is highly experienced and they are in safe
hands.
B. Proceed with the preoperative checklist as the consent form is already legally binding.
C. Explain the risks and benefits of the surgery to the client using simplified medical terms.
D. Inform the surgeon that the client requires further clarification of the procedure’s risks.
Correct Answer: D
Explanation: The nurse’s primary role in informed consent is to witness the signature and
advocate for the patient’s understanding. If the patient indicates they do not understand
the risks, the nurse must notify the provider who is performing the procedure. It is outside
the nursing scope of practice to provide the initial explanation of surgical risks or benefits.
2. During the intraoperative phase, a client suddenly develops a heart rate of 130 bpm,
muscle rigidity, and a rapidly rising body temperature. Which medication should the nurse
anticipate the surgical team will administer immediately?
A. Dantrolene sodium
,B. Epinephrine
C. Naloxone
D. Atropine sulfate
Correct Answer: A
Explanation: The symptoms described are classic signs of malignant hyperthermia, a life-
threatening complication of general anesthesia. Dantrolene sodium is a skeletal muscle
relaxant that specifically treats this condition by stopping the release of calcium. Prompt
recognition and administration of this medication are critical for patient survival during
the intraoperative period.
3. A nurse is assessing a postoperative client who underwent abdominal surgery 6 hours ago.
The client is reluctant to use the incentive spirometer due to pain at the incision site. What is
the priority nursing intervention?
A. Administer prescribed analgesic medication and then encourage the use of the device.
B. Instruct the client on the importance of the device for preventing pneumonia.
C. Document the client’s refusal and notify the surgeon during morning rounds.
D. Allow the client to skip the current session and try again when they feel better.
Correct Answer: A
Explanation: Effective pain management is essential for facilitating postoperative
respiratory exercises like incentive spirometry. By administering analgesics first, the nurse
, reduces the pain barrier, allowing the patient to perform deep breathing more effectively.
This sequence is a standard nursing intervention to prevent atelectasis and subsequent
respiratory complications.
4. A client with chronic back pain is being switched from around-the-clock dosing to a Patient-
Controlled Analgesia (PCA) pump. Which statement by the client indicates a need for further
teaching?
A. I should push the button as soon as I feel the pain starting to increase.
B. I might still feel some pain, but it should be at a level that I can tolerate.
C. The pump is programmed so that I cannot accidentally give myself an overdose.
D. I will tell my wife to push the button for me if I am asleep and look uncomfortable.
Correct Answer: D
Explanation: PCA pumps are designed for patient-only use to ensure that the patient does
not receive medication while overly sedated. If a family member pushes the button while
the patient is asleep, it significantly increases the risk of respiratory depression. Education
must emphasize that only the patient is permitted to trigger a dose of medication.
5. A nurse is caring for an older adult client with severe visual impairment. Which
intervention is most effective for maintaining safety during mealtime?
A. Feed the client the entire meal to prevent spills and frustration.
B. Describe the location of the food items using the ‘clock’ method.
C. Provide only finger foods that do not require the use of utensils.
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing a client for an elective surgical procedure. Which action is most
appropriate when the client expresses a lack of understanding regarding the risks of the
surgery despite having signed the consent form?
A. Reassure the client that the surgical team is highly experienced and they are in safe
hands.
B. Proceed with the preoperative checklist as the consent form is already legally binding.
C. Explain the risks and benefits of the surgery to the client using simplified medical terms.
D. Inform the surgeon that the client requires further clarification of the procedure’s risks.
Correct Answer: D
Explanation: The nurse’s primary role in informed consent is to witness the signature and
advocate for the patient’s understanding. If the patient indicates they do not understand
the risks, the nurse must notify the provider who is performing the procedure. It is outside
the nursing scope of practice to provide the initial explanation of surgical risks or benefits.
2. During the intraoperative phase, a client suddenly develops a heart rate of 130 bpm,
muscle rigidity, and a rapidly rising body temperature. Which medication should the nurse
anticipate the surgical team will administer immediately?
A. Dantrolene sodium
,B. Epinephrine
C. Naloxone
D. Atropine sulfate
Correct Answer: A
Explanation: The symptoms described are classic signs of malignant hyperthermia, a life-
threatening complication of general anesthesia. Dantrolene sodium is a skeletal muscle
relaxant that specifically treats this condition by stopping the release of calcium. Prompt
recognition and administration of this medication are critical for patient survival during
the intraoperative period.
3. A nurse is assessing a postoperative client who underwent abdominal surgery 6 hours ago.
The client is reluctant to use the incentive spirometer due to pain at the incision site. What is
the priority nursing intervention?
A. Administer prescribed analgesic medication and then encourage the use of the device.
B. Instruct the client on the importance of the device for preventing pneumonia.
C. Document the client’s refusal and notify the surgeon during morning rounds.
D. Allow the client to skip the current session and try again when they feel better.
Correct Answer: A
Explanation: Effective pain management is essential for facilitating postoperative
respiratory exercises like incentive spirometry. By administering analgesics first, the nurse
, reduces the pain barrier, allowing the patient to perform deep breathing more effectively.
This sequence is a standard nursing intervention to prevent atelectasis and subsequent
respiratory complications.
4. A client with chronic back pain is being switched from around-the-clock dosing to a Patient-
Controlled Analgesia (PCA) pump. Which statement by the client indicates a need for further
teaching?
A. I should push the button as soon as I feel the pain starting to increase.
B. I might still feel some pain, but it should be at a level that I can tolerate.
C. The pump is programmed so that I cannot accidentally give myself an overdose.
D. I will tell my wife to push the button for me if I am asleep and look uncomfortable.
Correct Answer: D
Explanation: PCA pumps are designed for patient-only use to ensure that the patient does
not receive medication while overly sedated. If a family member pushes the button while
the patient is asleep, it significantly increases the risk of respiratory depression. Education
must emphasize that only the patient is permitted to trigger a dose of medication.
5. A nurse is caring for an older adult client with severe visual impairment. Which
intervention is most effective for maintaining safety during mealtime?
A. Feed the client the entire meal to prevent spills and frustration.
B. Describe the location of the food items using the ‘clock’ method.
C. Provide only finger foods that do not require the use of utensils.
