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A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

Postpone the procedure until the staff contacts the guardian.

Obtain consent from the client.

Prepare the client for surgery with implied consent.

Request that the provider sign the consent form.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Postponing the procedure could put the client at risk if the appendicitis worsens.

B. Obtaining consent from the client may not be possible due to the client's developmental disability.

C. Preparing the client for surgery with implied consent is appropriate when the client is unable to provide consent and the procedure is urgent.

D. Requesting that the provider sign the consent form is not appropriate because the provider cannot provide consent on behalf of the client.

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Correct Answer is C

Explanation

A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.

B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.

C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.

D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.

A. Administer prescribed diuretics in the evening. B. Use overhead lighting when checking equipment. C. Keep the door to the client's room closed. D. Provide the client with snug-fitting nightwear.

Correct Answer is C

Explanation

Rationale:

A. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.

B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.

C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.

D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.

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A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

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