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A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Contact the facility's ethics committee

Obtain consent from the client's employer

Limit care to comfort measures

Proceed with provision of medical care

Answer and Explanation

The Correct Answer is D

Proceed with provision of medical care.

A. Contact the facility's ethics committee: This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
B. Obtain consent from the client's employer: This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
C. Limit care to comfort measures: This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
D. Proceed with provision of medical care: This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.

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Correct Answer is D

Explanation

- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.

- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.

- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.

- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.

A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

Correct Answer is A

Explanation

- A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.

- B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.

- C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.

- D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.

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A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Nursing Test Bank

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