A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

A client who has hearing loss with a friend interpreting

A client who has not spoken with the provider yet

A 15-year-old client whose caregiver is not at the bedside.

A married 16-year-old client accompanied by their spouse

Answer and Explanation

The Correct Answer is D

A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.

B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.

C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.

D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hold the catheter with the dominant hand during insertion: The dominant hand should be used to insert the catheter because it provides better control and precision during the sterile procedure. The nondominant hand is used to expose and maintain the position of the urethra but is considered contaminated once touching the client.

B. Advance catheter 7.5 cm (3 in) after urine begins to flow: The catheter should be advanced approximately 2.5 to 5 cm (1 to 2 inches) further after urine appears, not 7.5 cm. Advancing too far could cause discomfort or trauma to the bladder.

C. Hang collection bag below the level of the bladder: While this is an important step in managing the catheter after insertion to prevent backflow and infection, it does not specifically pertain to the insertion process itself.

D. Lubricate the catheter 12.5 cm (5 in) prior to insertion: Typically, for female catheterization, about 2.5 to 5 cm (1 to 2 inches) of the catheter is lubricated, not 12.5 cm. Excessive lubrication is unnecessary and may cause difficulty during insertion.

A. Erythema B. Blood C. Edema D. Pruritus

Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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