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.

Obtain consent from the surgeon.

Contact the facility's ethics committee for guidance

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

Answer and Explanation

The Correct Answer is A

A. In an emergency situation where a patient is unconscious and unable to give consent, and there is no available family member or designated surrogate to provide consent, healthcare providers can proceed with life-saving treatment under the principle of implied consent. This principle assumes that a reasonable person would consent to treatment if they were able to do so.

B. The surgeon cannot give consent for the patient. Consent must come from the patient or a legally authorized representative.
C. In situations where consent cannot be obtained from the patient or a legally authorized representative, involving the ethics committee can be a prudent course of action. However, this may delay emergency care.
D. This option may be appropriate if there is a reasonable expectation that a family member or legally authorized representative will arrive within a reasonable timeframe. However, in emergency situations where immediate intervention is necessary to save the patient's life or prevent serious harm, waiting for consent may not be feasible.

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Correct Answer is D

Explanation

D. It is the most appropriate action to ensure accuracy and reliability of the blood pressure reading. Discrepancies in blood pressure readings between arms may indicate arterial abnormalities or differences in blood pressure measurement technique. Rechecking the client's blood pressure in her other arm allows the nurse to verify the consistency of the reading and identify any potential discrepancies.
A. Requesting that another nurse check the client's blood pressure in 30 minutes, is not appropriate as the next course of action. If there is a concern about the accuracy of the blood pressure reading, it's best to first verify the reading using another method, such as rechecking in the other arm, before determining the need for further monitoring.
B. Ensuring that the width of the blood pressure cuff is 50% of the client's upper arm circumference, is a standard recommendation for obtaining accurate blood pressure measurements. However, in this scenario, the priority is to verify the accuracy of the initial reading by rechecking in the other arm.
C. Repositioning the client supine and rechecking her blood pressure, may not be necessary at this point unless there are specific indications or concerns about orthostatic hypotension or positional effects on blood pressure. The immediate priority is to verify the accuracy of the initial reading by rechecking in the other arm.

A. Rub the peristomal skin dry after cleaning. B. Apply the pouch while the skin barrier is still damp. C. Change the pouch once every 24 hr. D. Ensure the pouch is 0.32 cm (1 in) larger than the stoma

Correct Answer is D

Explanation

D. It's important to choose a pouching system that provides a snug fit around the stoma without covering the stoma itself. Leaving a small margin (usually around 0.32 cm or 1/8 inch) between the stoma and the opening of the pouch helps to prevent irritation or pressure on the stoma, allowing for proper drainage and protecting the peristomal skin.
A. After cleaning the peristomal skin around the stoma, it's important to ensure that the area is completely dry before applying the pouching system. Moisture on the skin can prevent the adhesive from sticking properly, leading to leakage and skin irritation. However, rubbing can lead to more skin damage.
B. It's essential to ensure that the peristomal skin is completely dry before applying the pouching system. Applying the pouch while the skin barrier is still damp can compromise the adhesive and lead to poor adherence, increasing the risk of leakage and skin irritation.
C. The frequency of pouch changes depends on factors such as the type of stoma, output consistency, and individual client needs. In many cases, pouches can be worn for several days before needing to be changed. However, if the pouch becomes soiled, loose, or odorous, it should be changed promptly to maintain skin integrity and prevent infection.

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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?

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