A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

Obtain telephone consent from the facility administrator before the surgery.

Delay the surgery until the nurse can obtain informed consent.

Ask the anesthesiologist to sign the consent.

Transport the client to the operating room without verifying informed consent.

Answer and Explanation

The Correct Answer is D

A.   Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B.   Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C.   Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D.   Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.

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Correct Answer is D

Explanation

Choice A Rationale: While it is important to identify the staff member responsible for leaving sensitive information accessible, it is not the first action that should be taken. The immediate risk of a confidentiality breach must be addressed before investigating the cause.
Choice B Rationale: Notifying the charge nurse is a necessary step, but it is not the most immediate action required. The priority is to secure the confidentiality of the client's information.
Choice C Rationale: Informing the visitor about the confidentiality of records is crucial, but the first action should be to prevent further viewing of the information.
Choice D Rationale: Closing the computer program is the first and most direct action to secure the client's medical information and prevent any further unauthorized access. This action immediately addresses the privacy breach and protects the client's confidential information.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client's bed to 30° during mealtime C. Withholding fluids until the end of the meal D. Instructing the client to place her chin toward her chest when swallowing

Correct Answer is B

Explanation

A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.

B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.

C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.

D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.

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A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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