A nurse enters a client’s room to obtain informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

Educate the client about the risks of refusing the procedure

Complete an incident report

Inform the provider that the client requires clarification about the procedure

Answer the client’s questions concerning the procedure

Answer and Explanation

The Correct Answer is C

a.   While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b.   Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c.   When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d.   While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.

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Correct Answer is D

Explanation

a. Clients with compromised immunity are often placed in protective environments, but not necessarily in negative air pressure rooms. These rooms are typically reserved for clients on airborne precautions.
b. An N95 respirator is required for airborne precautions, not droplet precautions. A regular surgical mask is sufficient for droplet precautions.

c. Contact precautions primarily focus on preventing the transmission of pathogens through direct or indirect contact. Visitors are usually instructed to wear personal protective equipment (PPE) when entering the room, but the focus is on healthcare workers wearing PPE during patient care.
d. A client on airborne precautions (e.g., for tuberculosis or measles) should wear a mask (preferably an N95 or equivalent) when leaving the room to prevent spreading airborne pathogens

A. Measuring oxygen saturation for a client who has dyspnea B. Performing nasal hygiene for a client who has an NG tube C. Pouching a client's ostomy bag for a new colostomy D. Inserting a rectal suppository for a client who is vomiting

Correct Answer is C

Explanation

a. Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b. Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c. Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d. Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.

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A nurse enters a client’s room to obtain informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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