Correct Answer: B

Rationale: Telling the client about the benefits of the surgery might seem helpful, but it does not address the client's immediate concern. The client has expressed a clear decision to refuse the surgery, and the nurse must respect this decision by informing the surgeon. This approach aligns with the ethical principle of respecting patient autonomy. Letting the client know that their surgeon will be notified of their decision is the correct action. This respects the client's autonomy and ensures that the surgeon is aware of the client's wishes. It also allows for further discussion between the client and the surgeon, where the client can receive more detailed information and support. Reassuring the client that it is expected to be nervous before surgery is supportive but does not address the client's refusal. While it is important to acknowledge the client's feelings, the nurse must also take appropriate steps to respect the client's decision and inform the surgeon. Informing the client that it is too late to stop the surgery is incorrect and unethical. Patients have the right to refuse treatment at any time, and it is the nurse's duty to respect and facilitate this decision.

Correct Answer: A

Rationale: Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively. Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface. Holding the dropper 3 cm (1.2 in) away from the client's eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination. Massaging the client's eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.

Correct Answer: B,C,D

Rationale: Language isn’t confirmed by the signature; interpreters can be used. The nurse’s signature verifies the client signed in their presence, was not coerced, and has legal authority (e.g., is competent). Mental health conditions don’t preclude consent if capacity is intact.

Correct Answer: D

Rationale: Asking the provider is cautious but less proactive; pushing prescribed meds dismisses autonomy; the FDA doesn’t fully regulate TCM. Arranging a referral respects the client’s choice and facilitates safe exploration.

Correct Answer: D

Rationale: The NLN focuses on education, The Joint Commission on accreditation, and the Patients Bill of Rights on patient rights. State-based Nurse Practice Acts legally define the scope of nursing practice.