A nurse in an emergency department is caring for a child who reports being sexually abused by a family member.

Which of the following actions should the nurse take?

Choice A reason:

Explaining the procedure to the client before verifying informed consent is not an appropriate action: While it is essential to explain the procedure to the client and ensure they have a clear understanding of what they are consenting to, this step typically occurs before the informed consent form is presented. The purpose of the informed consent form is to document that the client has received adequate information and has given their consent voluntarily

Choice B reason:

Confirming the client's signature is authentic is the correct action. Verifying the record of informed consent for a client scheduled for surgery involves several important steps. Of these, the nurse's primary responsibility is to ensure that the client's signature on the informed consent form is authentic. This means ensuring that the client themselves or their authorized representative has signed the form willingly and without coercion.

Choice C reason:

Providing information on the informed consent form about the benefits of the surgery is not an appropriate action: The informed consent form typically contains information about the procedure, its risks, possible complications, and alternatives, but it is not the nurse's responsibility to provide this information. The healthcare provider or surgeon is responsible for explaining the details of the surgery to the client before obtaining their consent.

Choice D reason:

Informing the client about the condition that requires treatment is not an appropriate action: The responsibility of informing the client about their medical condition, the need for treatment, and the available options lies with the healthcare provider or surgeon, not the nurse. The nurse may assist in providing information or answering questions, but the primary responsibility for discussing the medical condition lies with the provider.

The correct answers are B and C.

Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.

Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.

Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.

Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.