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 ["B","E","F"]

Explanation

A. Phosphorous level: While phosphorus is important for bone health, deficiencies are rare in individuals with a normal diet and are not typically associated with osteoporosis.

B. Vitamin D level: Vitamin D is essential for calcium absorption and bone health. Inadequate vitamin D levels can lead to decreased calcium absorption and increase the risk of osteoporosis.

C. Smoking history: Smoking is a risk factor for osteoporosis due to its adverse effects on bone metabolism, but the client is a nonsmoker, so this finding does not apply.

D. Alcohol use: Excessive alcohol consumption is a risk factor for osteoporosis, but the client does not drink alcohol, so this finding does not apply.

E. Activity level: A sedentary lifestyle is a risk factor for osteoporosis. Weight-bearing exercises and physical activity help maintain bone density and strength, reducing the risk of osteoporosis.

F. Lactose intolerant: Lactose intolerance may lead to decreased intake of dairy products, which are a significant source of calcium. Inadequate calcium intake can contribute to decreased bone density and increase the risk of osteoporosis.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Reposition the client supine and recheck her BP. C. Recheck the client's BP in her other arm for comparison. D. Request that another nurse check the client's BP in 30 min.

Correct Answer is C

Explanation

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.

C. Recheck the client's BP in her other arm for comparison.

When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.

D. Request that another nurse check the client's BP in 30 min:

Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.

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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

Correct Answer is ["B","E","F"]

Explanation

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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