A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Prepare the client for surgery.

Contact the facility's ethics committee for guidance.

Keep the client stable until a family member arrives to give consent.

Obtain consent from the surgeon.

Answer and Explanation

The Correct Answer is A

A. Prepare the client for surgery: In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.

B. Contact the facility's ethics committee for guidance: Contacting the ethics committee can be helpful for guidance on how to handle consent issues in complex situations, but it might not provide a timely solution for immediate emergency situations.

C. Keep the client stable until a family member arrives to give consent: While stabilizing the client's condition is important, waiting for a family member to arrive to give consent may not be feasible in emergency situations where immediate treatment is necessary. The nurse should seek guidance from appropriate channels to determine the best course of action.

D. Obtain consent from the surgeon: Surgeons do not have the authority to provide consent for treatment on behalf of a client who is unconscious. Consent must come from a legally authorized decision-maker, such as the client themselves if they have previously provided informed consent, or a designated healthcare proxy.

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Correct Answer is A

Explanation

A. Assault.

Assault is the threat or apprehension of harmful or offensive contact. In this scenario, the nurse is making a threat to administer medication by injection if the client doesn't comply with swallowing pills. Even though the nurse hasn't physically carried out the action yet, the threat itself constitutes assault. The client feels threatened by the nurse's statement, creating apprehension of harm or offensive contact.

B. Defamation: Defamation involves making false statements that harm a person's reputation. There is no indication of defamation in this scenario.

C. Battery: Battery involves the intentional and unauthorized touching of another person. While administering medication by injection without consent could be considered battery, the nurse has only made a threat at this point, not carried out the action.

D. Invasion of privacy: Invasion of privacy involves intruding into someone's private affairs without permission. There is no indication of invasion of privacy in this scenario.

A. Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube. B. Cleanse the skin around the stoma with full-strength hydrogen peroxide. C. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. D. Wear clean gloves while cleaning the inner cannula.

Correct Answer is C

Explanation

A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.

B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.

C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.

D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.

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A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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