A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain.
The nurse notes that the patient’s chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Choice A rationale

Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.

Choice B rationale

Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.

Choice C rationale

Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

Choice D rationale

Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

Choice A rationale

The patient has the right to withdraw their informed consent at any time, even after signing the consent form. This is a fundamental principle of patient autonomy and respect for the individual’s rights. The nurse should respect the patient’s decision and notify the surgeon that the patient wishes to withdraw informed consent for the procedure. This allows the healthcare team to reassess the situation, provide further information if necessary, and make appropriate adjustments to the care plan.

Choice B rationale

While informing the surgical team to cancel the surgery might be a subsequent step, it is not the immediate action the nurse should take. The first action should be to respect the patient’s autonomy and communicate their decision to the surgeon.

Choice C rationale

Proceeding with the preparation of the patient for the surgical procedure against their expressed wishes would be a violation of the patient’s rights. It is essential to respect the patient’s autonomy and their right to make decisions about their own healthcare.

Choice D rationale

Reminding the patient that a signed informed consent form is a legally binding document is incorrect. Informed consent is not a contract, and the patient has the right to withdraw consent at any time. The purpose of informed consent is to ensure that the patient understands the procedure, its risks and benefits, and alternatives, and makes an informed decision.