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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
Correct Answer is B
Explanation
Rationale:
A. Clamping the tube when going for a walk is not recommended because it can cause urine to back up into the bladder.
B. Keeping the drainage bag below the level of the waist is recommended to prevent reflux of urine and reduce the risk of infection.
C. Emptying the drainage bag once a day may not be frequent enough to prevent urinary stasis and infection.
D. Applying antiseptic ointment to the tip of the penis is not recommended because it can cause irritation and discomfort.
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