A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

Notify risk management before initiating treatment.

Proceed with treatment without obtaining written consent.

Contact the client's next of kin to obtain consent for treatment.

Have the client sign a consent for treatment.

Answer and Explanation

The Correct Answer is B

A.   Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B.   In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C.   Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D.   Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.

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Correct Answer is D

Explanation

A. A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,
making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.

A. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions." B. "I will place a client who has compromised immunity in a negative-pressure airflow room." C. "I will have a client who is on airborne precautions wear a mask when out of her room." D. "I will wear an N95 respirator mask when caring for a client who is on droplet precautions"

Correct Answer is C

Explanation

A. Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
B.A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client.
C. Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
D. An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

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A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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