Solutions
After completing the admission interview, the nurse reviews Ms.
Jackson's medical record and notes that the surgical consent
form is filled out but is not signed by the client.
What action should the nurse take?
A) Ask Ms. Jackson if she has received sufficient information to
sign the consent form.
B) Call the operating room and notify the staff that the surgery
needs to be cancelled.
C) Notify the surgeon of the need to come to the client's room so
the consent can be signed.
D) Inform a family member of the need to serve as a witness to
the client's signature. Correct Answers A) Ask Ms. Jackson if
she has received sufficient information to sign the consent form.
The nurse may witness the client's signature if the nurse is able
to determine that the client has been sufficiently informed of the
necessary information.
After Ms. Jackson ambulates with the physical therapist, the
nurse prepares to change the surgical dressing. While obtaining
supplies, the nurse reviews the sterile procedure to be followed.
At what step in the procedure should the nurse don sterile
gloves?
A) Prior to removing the dressing on the client's hip.
B) Before opening the new sterile dressing package.
C) Before cleansing the client's hip incision.
,D) After cleansing the client's hip incision. Correct Answers
C) Before cleansing the client's hip incision.
When using surgical asepsis for wound care, the sterile gloves
should be donned prior to cleaning the wound and applying the
new sterile dressing.
After Ms. Jackson stops crying, she states, "My father was in so
much pain before he died. Talking about pain brings back so
many memories."
How should the nurse respond?
A) "We do not need to talk about pain control today if it makes
you sad."
B) "Perhaps you need to see a counselor to help you resolve
your grief."
C) "It sounds as if you went through a difficult time when your
father died."
D) "You need to focus on your own needs now and not on past
memories." Correct Answers C) "It sounds as if you went
through a difficult time when your father died."
This open-ended acknowledgment of the client's distress is
therapeutic and allows the opportunity for further discussion by
the client if desired.
Based on the lab data provided by the nurse, the healthcare
provider prescribes the transfusion of two units of packed red
blood cells as soon as possible. Once the first unit of packed red
blood cells is ready, the nurse obtains the blood from the blood
, bank. When the nurse enters Ms. Jackson's room to begin the
transfusion, the UAP is giving Ms. Jackson a partial bath.
What action should the nurse take?
A) Place the unit of blood in the medication refrigerator until the
client's personal care is completed.
B) Hang the transfusion of packed cells while the UAP
continues to complete the client's personal care.
C) Lock the unit of blood in the computerized medication cart
and assist the UAP in completing the personal care.
D) Return the blood to blood bank and send the UAP to obtain
the blood when the personal care is completed. Correct
Answers B) Hang the transfusion of packed cells while the
UAP continues to complete the client's personal care.
Transfusion of the blood is a higher priority than personal care.
If necessary, the remainder of the care can be delayed.
During the postoperative assessment, the nurse observes Ms.
Jackson's surgical site. The left hip dressing has a moderate
amount of sanguineous drainage.
What action should the nurse implement? (select all that apply)
A) Apply pressure to the site.
B) Elevate the leg on a pillow.
C) Observe the linens under the hip.
D) Use sterile technique to replace the dressing.
E) Mark the amount of drainage on the dressing. Correct
Answers C) Observe the linens under the hip.