Fundamentals Nursing Test Bank (61-65)

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61. After receiving detailed information about a colonoscopy from the provider, the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?

a) contact the provider to obtain informed consent
b) obtain a verbal informed consent from the client
c) have two nurses witness the client sign with an X
d) clarify information to the client with another nurse

62. The nurse documents an entry regarding client care in the client's medical record. When checking the entry, the nurse notices some incorrect information. Which should the nurse implement?

a) obliterate the incorrect information with a black marker
b) use correction fluid to cover up the incorrect information
c) erase the error completely and write in the correct information
d) draw a line through the incorrect information and initial the change

63. The nurse prepares to suction a client through a tracheostomy tube. Which should the nurse wear to perform this procedure?

a) mask, gown, and a cap
b) mask, sterile gloves, and a cap
c) gown, mask, and sterile gloves
d) goggles, mask, and sterile gloves

64. The nurse instructs a client how to use crutches safely for ambulating at home. Which instruction should the nurse recommend to minimize the risk of falls?

a) remove all area rugs
b) wear soft, slip-on shoes
c) use the bathtub's grab bars
d) remove pets from the home

65. The nurse observes than an older postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to help avoid episodes of agitation?

a) gently hold the client's hand while speaking
b) wait until the client's agitation has subsided
c) speak while moving slowly toward the client
d) speak to the client from the entrance to the room





Fundamentals Nursing Test Bank
Answers and Rationale

61) C

- Nurses are responsible to make sure the signed informed consent form is in the client's medical record prior to a procedure and for clarifying facts presented by the provider. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the provider. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.

62) D

- To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.

63) D

- The nurse should wear a mask and goggles when suctioning the client. Sterile gloves are also worn unless suctioning is performed using a closed suctioning system. A mask offers full protection of the nurse's nose and mouth, and goggles protect the nurse's eyes from getting splashed with sputum. A gown protects the nurse's uniform, and a cap protects the nurse's hair, but these items are not required for suctioning a client.

64) A

- To reduce the risk of falls, the nurse recommends the removal of all obstacles and trip hazards from the home. Tie-on shoes with nonslip soles should be worn while crutch walking. Grab bars in the bath tub or shower will not necessarily assist the client while walking with crutches. Not all pets are trip hazards (e.g., fish, birds, guinea pigs).

65) C

- Speaking and moving slowly toward the client will prevent the client from becoming further agitated, because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.


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Fundamentals Nursing Test Bank (1-5)


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Fundamentals Nursing Test Bank (66-70)