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.

None

Answer and Explanation

The Correct Answer is A

A. In emergency situations where the client is unconscious and requires immediate life-saving surgery, implied consent is assumed. The nurse should prepare the client for surgery without waiting for family members or a formal consent process. Delaying treatment could jeopardize the client's life.

B. Contacting the ethics committee could delay the urgent care needed in an emergency situation. Immediate action should be taken in the best interest of the client.

C. Waiting for a family member to arrive could delay critical care, which may lead to worsening of the client's condition or even death.

D. The surgeon does not need to provide consent. It is the healthcare team's responsibility to act in the client's best interest when the client is unable to provide consent in an emergency.

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Correct Answer is B

Explanation

A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.

A. "I will perform ankle and knee exercises every hour." B. "I will have my partner help me change positions every 4 hours." C. "I will remove my antiembolic stockings while I am in bed." D. "I will hold my breath when rising from a sitting position."

Correct Answer is A

Explanation

A. Regular ankle and knee exercises help prevent muscle atrophy due to immobility.
B. Changing positions every 4 hours is helpful, but more frequent movement is recommended.
C. Antiembolic stockings should be worn when immobile to prevent blood clots.
D. Holding breath during movement doesn't contribute to reducing adverse effects of immobility.

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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

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 B

Explanation

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Correct Answer is A

Explanation

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