A nurse is caring for a client who has a prescription for warfarin.

Which of the following laboratory tests should the nurse monitor?

Choice A Reason:

Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.

Choice B Reason:

Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.

Choice C Reason:

Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.

Choice D Reason:

Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.

Choice A Reason:

Positioning the knot of the rope at the top of the pulley is incorrect. The knot should be placed at the foot of the bed to ensure proper traction.

Choice B Reason:

Removing the weights for 20 minutes without a healthcare provider's order is not appropriate. If the client experiences severe pain, the nurse should assess the client, evaluate the traction system, and notify the healthcare provider if necessary.

Choice C Reason:

Applying 6.8 kg (15 lb) of weight for use in traction is not the standard practice. The amount of weight used in Buck's traction varies depending on the healthcare provider's orders and the client's specific condition. The nurse should follow the healthcare provider's orders regarding the amount of weight to apply.

Choice D Reason:

Compare bilateral pedal pulses. When caring for a client with Buck's traction, it is essential to regularly assess the circulation to the extremity in traction. Comparing bilateral pedal pulses helps the nurse determine if there are any circulation issues in the affected leg. If the client's circulation is compromised, it can lead to complications such as deep vein thrombosis (DVT) or compartment syndrome.