A nurse is caring for a client who is comatose and requires a non-life-threatening surgical procedure. Which of the following actions should the nurse take?

Ensure that the health care provider has consulted with another team member.

Ensure that the client's 16-year-old child supports the provider's decision for surgery.

Determine if the procedure is medically necessary for the client.

Determine if the health care surrogate understands the risks and benefits of the procedure.

Answer and Explanation

The Correct Answer is D

A. Ensure that the health care provider has consulted with another team member: While consultation may be part of ethical decision-making, it is not the primary action the nurse should take when a comatose client requires consent. The priority is confirming that informed consent is obtained from the appropriate decision-maker.

B. Ensure that the client's 16-year-old child supports the provider's decision for surgery: Minors cannot legally provide consent for medical procedures. The nurse should focus on the legal health care surrogate or guardian rather than the opinion of a minor child.

C. Determine if the procedure is medically necessary for the client: Assessing medical necessity is the provider’s responsibility. The nurse’s role is to advocate for the client by ensuring informed consent is obtained and the surrogate understands the procedure, risks, and benefits.

D. Determine if the health care surrogate understands the risks and benefits of the procedure: The nurse should confirm that the health care surrogate has received adequate information and understands the risks, benefits, and alternatives to the procedure. This ensures ethical and legal consent is obtained for a client unable to make decisions.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E","F","G"]

Explanation

A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.

B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.

C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.

D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.

E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.

F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.

G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.

A. Prepare for chest tube placement. B. Ensure that the client has venous access. C. Place the client in High Fowler's position. D. Activate the rapid response team. E. Administer fondaparinux as prescribed. F. Administer midazolam as prescribed.

Correct Answer is ["B","C","D","E"]

Explanation

A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first.

B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications.

C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload.

D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration.

E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea.

F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.

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A nurse is caring for a client who is comatose and requires a non-life-threatening surgical procedure. Which of the following actions should the nurse take?

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