Question

A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

Answer 1

Correct Answers:

Notify the charge nurse of the client's concerns about surgery.

Rationale :

🔷 When a client expresses fear and uncertainty after signing consent, it indicates potential lack of informed consent, which legally and ethically invalidates the agreement.

🔷 The priority is to escalate this concern to the charge nurse or provider so they can reassess the client's understanding and provide clarification.

🔷 The nurse must advocate for the client’s autonomy and ensure consent is voluntary and informed.

🔷 Proceeding without addressing these doubts may violate ethical practice and patient rights.

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Answer 2

Correct Answers:

Ask the parents to explain what they understand about the child's diagnosis.

Rationale :

💠 Asking the parents what they understand helps assess knowledge gaps and beliefs about hypospadias, guiding future teaching.

💠 Hypospadias does not resolve spontaneously, and early correction is recommended for normal urination and fertility.

💠 Clarifying their understanding is a therapeutic approach that promotes informed decision-making.

💠 It supports partnership and opens a dialogue without being judgmental.

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Answer 3

Correct Answers:

Blood urea nitrogen (BUN) and creatinine

Rationale :

🟣 Nephrotoxic antibiotics, such as aminoglycosides or vancomycin, can damage the kidneys; therefore, renal function must be assessed.

🟣 BUN and creatinine levels are key markers for kidney function and help evaluate the risk of toxicity.

🟣 Elevated levels may indicate the need for dose adjustment or alternative treatment.

🟣 Monitoring prevents cumulative damage and adverse outcomes.

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Answer 4

Correct Answers:

Auscultate all lung fields.

Rationale :

🔶 Left-sided heart failure causes pulmonary congestion, leading to crackles, dyspnea, and orthopnea.

🔶 Auscultation is the most direct way to detect fluid accumulation and respiratory compromise.

🔶 Early identification helps prevent worsening of symptoms like pulmonary edema.

🔶 This intervention is more immediately relevant than peripheral or systemic signs.

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Answer 5

Correct Answers:

Curling's ulcer.

Rationale :

⚫ Curling’s ulcer is an acute gastric erosion that can occur 3–10 days after major burns, due to stress-induced decreased perfusion to the GI tract.

⚫ This can lead to GI bleeding, which may be life-threatening.

⚫ Preventative measures include proton pump inhibitors (PPIs) and early enteral nutrition.

⚫ It is a critical complication despite the client appearing stable.

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Answer 6

Correct Answers:

Monitor the client's hearing.

Rationale :

🟢 Aminoglycosides (e.g., gentamicin) are known to cause ototoxicity, affecting the cochlear and vestibular systems.

🟢 Early signs include hearing loss, tinnitus, or vertigo.

🟢 Prompt detection may prevent permanent auditory damage.

🟢 Routine hearing assessment is part of safe drug administration.

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Answer 7

Correct Answers:

Report the findings to the charge nurse.

Rationale :

🔵 Sudden muscle soreness, fatigue, and warm skin may indicate drug toxicity, infection, or rhabdomyolysis if on statins.

🔵 These symptoms require clinical evaluation and labs, such as CK or liver enzymes.

🔵 Early reporting helps initiate life-saving interventions if needed.

🔵 Delegating or delaying may worsen the condition.

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Answer 8

Correct Answers:

"Are you planning to obey the voices?"

Rationale :

🟤 When a client hears voices (auditory hallucinations), the priority is safety—assess if commands are dangerous or violent.

🟤 Asking directly helps evaluate risk for harm to self or others.

🟤 This guides decisions about monitoring, medication, and possible hospitalization.

🟤 Addressing the hallucination content should always begin with assessing for command type.

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Answer 9

Correct Answers:

Observe how the UAP obtains temperatures.

Rationale :

⚪ The PN should first assess technique and method before assuming faulty equipment or retraining is needed.

⚪ Direct observation reveals if the UAP is using the device incorrectly or failing to wait the required time.

⚪ This respects the just culture model, which encourages coaching before correction.

⚪ Avoids unnecessary recalibration or escalation.

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Answer 10

Correct Answers:

"It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."

Rationale :

🌺 The response shows acceptance and support without pushing the client.

🌺 It respects the client’s emotional readiness to process the body image change.

🌺 Healing after mastectomy involves psychological as well as physical recovery.

🌺 Forcing conversation may increase distress and resistance.

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QLexNursing

1 :
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

2 :
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

3 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

4 :
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

5 :
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

6 :
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

7 :
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

8 :
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

9 :
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

10 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

QLexNursing

1 : A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

2 : The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

3 : Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

4 : The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

5 : The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

6 : The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

7 : A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

8 : A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

9 : The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

10 : At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

1 :
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

2 :
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

3 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

4 :
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

5 :
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

6 :
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

7 :
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

8 :
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

9 :
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

10 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?