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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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 A
Explanation
A) Place the client close to the nurses' station:
While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.
B) Cover the site with a stockinette dressing:
Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.
C) Administer a sedative:
Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.
D) Apply a soft mitten restraint:
This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.