Nurs 310 HESI Review

How should the nurse handle linens that are soiled with incontinent feces? Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. Place an isolation hamper in the client's room and discard the linens in it. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation.

Position prone with a small pillow below the diaphragm.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? Flush the lumen with the saline solution and administer the medication through the lumen. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Flush the lumen with the saline solution and administer the medication through the lumen.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? Generativity. Ego integrity. Identification. Valuing wisdom.

Generativity.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position.

Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.

What comment from the client indicates that the teaching has been effective? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase."

"I will limit my intake of beef to 4 ounces per week."

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? 0800, 1200, 1600, 2000. 0800. Every other day at 0800. 0800, 1200, 1600, 2000, 0000, 0400.

(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? Temperature increases from 98.8 to 99.0 F. Pulse rate decreases from 78 to 52 beats/min. Respiratory rate increases from 16 to 24 breaths/min. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Pulse rate decreases from 78 to 52 beats/min. Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions.

Rashes in the axillary, groin, and skin fold regions.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? Check for a blood return. Reposition the client's arm. Remove the IV site dressing. Flush the lock with saline.

Reposition the client's arm. If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? Sensory pattern, area, intensity, and nature of the pain. Trigger points identified by palpation and manual pressure of painful areas. Schedule and total dosages of drugs currently used for breakthrough pain. Sympathetic responses consistent with onset of acute pain.

Sensory pattern, area, intensity, and nature of the pain.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? Transferrin. Prealbumin. Serum albumin. Urine urea nitrogen.

Serum albumin. Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C).

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey salad, roll, vanilla ice cream.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? Administer a PRN antihypertensive prescription. Provide the client with an additional blanket. Encourage additional fluid intake. Turn the client q2h.

Turn the client q2h. (D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D).

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? Fiber. Folate. Ascorbic acid. Vitamin B12.

Vitamin B12. Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegetables and fruits.

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? Hydrogel. Exudate absorber. Wet to moist dressing. Transparent adhesive film.

Wet to moist dressing.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? Check capillary refill of toes on lower extremity with Unna's paste boot. Apply dressing to wound area before applying the Unna's paste boot. Wrap the leg from the knee down towards the foot. Remove the Unna's paste boot q8h to assess wound healing.

Check capillary refill of toes on lower extremity with Unna's paste boot.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities.

Give an around-the-clock schedule for administration of analgesics.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

A decreased flow rate could result in the formation of a thrombosis.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? Accused of diversion. Reported for stealing. Reported for a HIPAA violation. Accused of unprofessional conduct.

Accused of diversion. Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome.

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? Assessment. Analysis. Implementation. Evaluation.

Analysis. The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care.

A client is demonstrating a positive Chvostek's sign. What action should the nurse take? Observe the client's pupil size and response to light. Ask the client about numbness or tingling in the hands. Assess the client's serum potassium level. Restrict dietary intake of calcium-rich foods.

Ask the client about numbness or tingling in the hands. A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium.

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? Withdraw the tube and apply additional lubricant to the tube. Encourage the client to bear down and continue to insert the tube. Remove the tube and check the client for a fecal impaction. Ask the client to relax and run a small amount of fluid into the rectum.

Ask the client to relax and run a small amount of fluid into the rectum. If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken.

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A quasi-intentional tort because a similar mistake can happen to anyone. Failure to respect client autonomy to choose based on intentional tort law. Assault and battery with deliberate intent to deviate from the consent form. An unintentional tort because the client benefited from having the myelogram.

Assault and battery with deliberate intent to deviate from the consent form. The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) Pre-medicate the client with an analgesic. Inform the client of the plan for moving to the chair. Obtain and place a portable commode by the bed. Ask the client to push the IV pole to the chair. Clamp the indwelling catheter.

Assess the client's blood pressure. Rationale The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment.

Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client.

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? The responses to biofeedback have not been well established and may be a waste of time and money. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. Although biofeedback is easily learned, it is most often used to manage exacerbation of symptoms. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? Portable syringe pump. Cassette infusion pump. Volumetric controller. Nonvolumetric controller.

Cassette infusion pump. A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices.

Chocolate pudding. The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow, require minimal chewing effort, and provide calories and protein.Gelatin does not provide any nutritional value and the other options require energy to chew and are more difficult to swallow than pudding.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses.

Closed-ended questions. Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client.

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? Low fat and low sodium foods. Combination of plant proteins to provide essential amino acids. Limited complex carbohydrates and fiber. Increased amount of vitamin C and beta carotene rich foods.

Combination of plant proteins to provide essential amino acids. A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? Continue gabapentin. Discontinue ibuprofen. Add aspirin to the protocol. Add oral methadone to the protocol.

Continue gabapentin. Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given "around the clock" rather than by the client's PRN requests.

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? Review the client's most recent laboratory reports. Refer the client and family members for hospice care. Notify the hospital ethics committee of the client situation. Determine who is legally empowered to make decisions.

Determine who is legally empowered to make decisions.

While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? Discontinue the administration of the bolus feeding. Auscultate the client's breath sounds bilaterally. Elevate the head of the bed to a high Fowler's position. Administer a PRN dose of a prescribed antiemetic.

Discontinue the administration of the bolus feeding.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? Notify the charge nurse that a medication error occurred. Submit a medication variance report to the supervisor. Document the events that occurred in the nurses' notes. Discard the original medication administration record.

Document the events that occurred in the nurses' notes.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? Elevate the head of the bed and attempt to palpate the site again. Document the presence and volume of the pulse palpated. Use a thigh cuff to measure the blood pressure in the leg. Record the presence of pitting edema in the inguinal area.

Document the presence and volume of the pulse palpated.

When making the bed of a client who needs a bed cradle, which action should the nurse include? Teach the client to call for help before getting out of bed. Keep both the upper and lower side rails in a raised position. Keep the bed in the lowest position while changing the sheets. Drape the top sheet and covers loosely over the bed cradle.

Drape the top sheet and covers loosely over the bed cradle. A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics.

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? Empty the client's urinary drainage bag. Draw up the irrigating solution into the syringe. Secure the client's catheter to the drainage tubing. Use aseptic technique to instill the irrigating solution.

Draw up the irrigating solution into the syringe. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? Does not check capillary blood glucose as directed. Occasionally forgets to take daily prescribed medication. Cannot identify signs or symptoms of high and low blood glucose. Eats anything and does not think diet makes a difference in health.

Eats anything and does not think diet makes a difference in health.

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? Solicit information on hospitalization from the insurance company. Look up previous medical records from archived hospital documents. Ask the client to discuss previous hospitalizations in the last 5 years. Elicit specific facts about past hospitalizations with direct questions.

Elicit specific facts about past hospitalizations with direct questions. Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? Review the client's medical record for an advance directive. Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice. Evaluate the client's mental status for competence to refuse treatment.

Evaluate the client's mental status for competence to refuse treatment.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Give the missed dose at 1300 and change the schedule to administer daily at 1300.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? Bradycardia. Increase in pulse rate. Peripheral vasodilation. Increase in cardiac output.

Increase in pulse rate.

Which statement is an example of a correctly written nursing diagnosis statement? Altered tissue perfusion related to congestive heart failure. Altered urinary elimination related to urinary tract infection. Risk for impaired tissue integrity related to client's refusal to turn. Ineffective coping related to response to positive biopsy test results.

Ineffective coping related to response to positive biopsy test results. The first part of the nursing diagnosis statement is the "diagnostic label" and is followed by "related to" the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's "response," which the nurse can provide support, reflection, and dialogue.

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? Ensure cultural customs are observed. Increase oxygen flow to 4L/minute. Auscultate bilateral lung fields. Inform the family that death is imminent.

Inform the family that death is imminent. An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches.

The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? Notify the surgeon that the consent form has not been signed. Read the consent form to the client before witnessing the client's signature. Determine if the client's spouse is willing to sign the consent form. Administer an opioid antagonist prior to obtaining the client's signature.

Notify the surgeon that the consent form has not been signed Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent.

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? Ensure that the client's perineal area is cleansed twice a day. Maintain accurate documentation of the fluid intake and output. Encourage frequent ambulation if allowed or regular turning if on bedrest. Obtain a prescription for removal of the catheter as soon as possible.

Obtain a prescription for removal of the catheter as soon as possible. The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis.

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? Stage 1 pressure sore draining sero-sanguineous drainage. Pressure sore at bony prominence with exudate noted. One-inch pressure sore draining serous fluid. Pressure sore on heel with a small amount of purulent drainage.

One-inch pressure sore draining serous fluid.