A nurse enters a client’s room to witness an 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 the incident report
Inform the provider that the client requires clarification about the procedure
Answer the client’s questions concerning the procedure
The Correct Answer is C
a. Educate the client about the risks of refusing the procedure:
This option suggests providing information about the potential consequences of not undergoing the gastroscopy. While educating the client about risks is essential, the immediate concern is the client's lack of understanding about the procedure itself.
b. Complete the incident report:
Filling out an incident report is typically reserved for situations where there has been an actual incident, such as a medical error or adverse event. In this case, the client's lack of understanding does not constitute an incident but rather a need for clarification.
c. Inform the provider that the client requires clarification about the procedure:
This is the correct action. It involves escalating the issue to the provider responsible for performing the gastroscopy. The provider can then address the client's concerns, answer questions, and provide additional information to ensure informed consent.
d. Answer the client’s questions concerning the procedure:
While answering the client's questions is important, it's not solely the nurse's responsibility to ensure the client understands the procedure. The provider, who will perform the gastroscopy, should be informed of the client's confusion so they can address it effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Providing a 10-minute rest period prior to meals:
This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime:
The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.
c. Instructing the client to place her chin toward her chest when swallowing:
This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.
d. Withholding fluids until the end of the meal:
Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.
Correct Answer is A
Explanation
a. "I will wear a surgical mask within 3ft of the client":
This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.
b. "I will check that the room has a high-efficiency particulate air filtration system":
This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.
c. "I will wear an N95 respirator when providing care for the client":
This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.
d. "I will assign the client to a room with positive airflow":
This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.
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