A nurse is caring for a client who is receiving continuous IV therapy.

Exhibits

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Based on the client's manifestations, they developed

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and

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Rationale

A. Restlessness: Restlessness can be an early sign of hypovolemia due to blood loss. Reduced circulating volume leads to decreased oxygen delivery to tissues, including the brain, causing anxiety, agitation, or confusion. Monitoring for restlessness helps identify active bleeding before more overt signs appear.

B. Brisk capillary refill: Brisk capillary refill indicates good peripheral perfusion and adequate circulating volume. In the context of active bleeding, capillary refill would more likely be delayed due to hypovolemia.

C. Bounding pulses: Bounding pulses are associated with fluid volume excess rather than blood loss. In active bleeding, pulses are more likely to be weak, thready, and rapid as the body attempts to compensate for decreased blood volume.

D. Warm skin: Warm, dry skin generally reflects stable perfusion. Active bleeding often causes cool, clammy skin as vasoconstriction occurs to maintain blood flow to vital organs. Skin assessment provides important clues about hemodynamic status.

Rationale

A. The provider obtains verbal consent for the procedure without witnessing the client's signature: While verbal consent may be appropriate for some low-risk procedures, most invasive or high-risk procedures require written consent. Obtaining consent without documentation does not meet legal or ethical standards for informed consent and may place both the client and provider at risk.

B. The provider performing the procedure is responsible for obtaining informed consent: The provider who will perform the procedure must ensure the client understands the risks, benefits, alternatives, and potential outcomes. This responsibility ensures the client receives accurate, procedure-specific information from the person most qualified to answer questions and address concerns.

C. The nurse's role is to provide the client with initial information about the procedure prior to obtaining informed consent: The nurse’s role is to reinforce teaching, clarify information, and ensure the client comprehends the procedure. Nurses can answer questions and verify understanding but do not obtain legal consent for invasive procedures.

D. Clients are unable to change their mind once a consent form is signed: Clients have the right to withdraw consent at any time, even after signing the consent form. Respecting autonomy means that the client can refuse or discontinue a procedure without penalty, and this right must be communicated as part of the informed consent process.