Page 502 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Skills: Perioperative Care
Health Problem: N/A
Priority Concepts: Client Education; Gas Exchange
Reference: Ignatavicius, Workman, Rebar (2018), pp. 244, 281.

128. Answer: 3

Rationale: The nurse would assist the client to void immediately before surgery so
that the bladder will be empty. Oral hygiene is allowed, but the client should not
swallow any water. The client usually has a restriction of food and fluids for 6 to 8
hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase
in blood pressure and pulse is common during the preoperative period and is
usually the result of anxiety.
Test-Taking Strategy: Focus on the subject, preoperative care measures. Think
about the measures that may be helpful and promote comfort. Oral hygiene should
be administered, since it may make the client feel more comfortable. A client should
be nothing by mouth (NPO) for 6 to 8 hours before surgery rather than 24 hours. A
slight increase in blood pressure or pulse is insignificant in this situation.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Foundations of Care: Perioperative Care
Health Problem: N/A
Priority Concepts: Clinical Judgment; Palliative Care
Reference: Lewis et al. (2017), p. 310.

129. Answer: 4

Rationale: Every effort should be made to obtain permission from a responsible
family member to perform surgery if the client is unable to sign the consent form. A
telephone consent must be witnessed by 2 persons who hear the family member’s
oral consent. The 2 witnesses then sign the consent with the name of the family
member, noting that an oral consent was obtained. Consent is not informed if it is
obtained from a client who is confused, unconscious, mentally incompetent, or
under the influence of sedatives. In an emergency, a client may be unable to sign and
family members may not be available. In this situation, a surgeon is permitted
legally to perform surgery without consent, but the data in the question do not
indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also,
agency policies regarding informed consent should always be followed.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the data
in the question. Eliminate options 1 and 3 first. Option 1 will delay necessary
surgery, and option 3 is inappropriate. Option 2 is not an acceptable and legal role of
a charge nurse. Select option 4, since it is the only legally acceptable option: to obtain
a telephone permission from a family member if it is witnessed by 2 persons.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation

502