A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)
Undergoing cardiac catheterization
Receiving moderate sedation
Suctioning a tracheostomy tube
inserting a peripheral IV catheter
inserting an indwelling urinary catheter
Correct Answer : A,B
A) Undergoing cardiac catheterization:
Cardiac catheterization is an invasive procedure that involves threading a thin tube (catheter) through blood vessels to the heart. It carries potential risks, including bleeding, infection, and damage to blood vessels or the heart. Therefore, obtaining informed consent is essential to ensure that the client understands the procedure, its risks, benefits, and alternatives before undergoing it.
B) Receiving moderate sedation:
Moderate sedation (conscious sedation) is a drug-induced state of depressed consciousness during which the client remains responsive to verbal commands. While it is less invasive than general anesthesia, it still carries risks, including respiratory depression, hypotension, and allergic reactions. Informed consent is required to ensure that the client understands the potential side effects and complications associated with sedation.
C) Suctioning a tracheostomy tube:
Suctioning a tracheostomy tube is a routine nursing intervention to remove secretions and maintain airway patency. It does not typically require informed consent unless there are specific circumstances or the client's condition warrants additional explanation or consent, such as if the client is at risk for complications or discomfort during the procedure.
D) Inserting a peripheral IV catheter:
Inserting a peripheral IV catheter is a common nursing procedure that typically does not require informed consent unless there are unusual circumstances or the client's condition warrants additional explanation or consent, such as if the client has specific concerns or medical conditions that may affect the procedure.
E) Inserting an indwelling urinary catheter:
Inserting an indwelling urinary catheter is a routine nursing procedure commonly performed to drain urine from the bladder. Informed consent may be required in certain situations, such as if the client lacks decision-making capacity or if the procedure involves specific risks or considerations that require explanation to the client or their legal representative. However, in most cases, informed consent is obtained as part of the general consent for treatment upon admission to the healthcare facility.
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Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A) Assist in checking a unit of packed RBCS to administer to a client:
Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.
B) Regulate the client's infusion pump after initiating a heparin drip infusion:
Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.
C) Teach a client about hemodialysis:
Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.
D) Create a plan of care for a client's discharge:
Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.
Correct Answer is D
Explanation
A) Triclosan:
Triclosan is an antimicrobial agent commonly found in soaps, hand sanitizers, and other personal care products. While it has broad-spectrum antimicrobial properties, it is not specifically recommended for hand hygiene in the context of C. difficile infection. Alcohol-based antiseptic rubs are preferred due to their rapid and effective action against C. difficile spores.
B) Chlorhexidine gluconate:
Chlorhexidine gluconate is an antimicrobial agent commonly used as a surgical scrub and skin cleanser. While it is effective against a wide range of microorganisms, including bacteria and fungi, its efficacy against C. difficile spores is limited compared to alcohol-based antiseptic rubs. Therefore, it is not the preferred choice for hand hygiene in the context of C. difficile infection.
C) Alcohol-based antiseptic rub:
Hand hygiene is crucial in preventing the transmission of Clostridium difficile, a bacterium that can cause severe gastrointestinal infection. Alcohol-based antiseptic rubs are not highly effective against C. difficile spores. Thorough handwashing with soap and water has demonstrated superior antimicrobial activity compared to alcohol-based rubs and are preferred for hand hygiene in such situations.
D) Non-antimicrobial soap:
Clostridium difficile (C. difficile) is a bacterium that can cause severe gastrointestinal infection, and proper hand hygiene is essential in preventing its transmission. While alcohol-based antiseptic rubs are effective against many pathogens, including C. difficile, non-antimicrobial soap and water are preferred for hand hygiene after caring for a client with C. difficile. Non-antimicrobial soap helps to mechanically remove C. difficile spores from the hands, reducing the risk of transmission. Although alcohol-based rubs are convenient and effective in many situations, they may not be as effective as soap and water for removing spores and should be used in conjunction with thorough handwashing when caring for clients with C. difficile.
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