A nurse is observing an assistive personnel (AP). For which of the following actions by the AP should the nurse intervene?

The correct answer is Choice C.

Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.

Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.

Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.

Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.

The correct answer is choice C. The nurse does not cause any harm to the client.

Choice A rationale:

While having a license to practice nursing in the state where the event occurred is important for professional practice, it is not a specific requirement for the Good Samaritan law to provide civil immunity.The Good Samaritan law generally protects individuals who provide emergency care in good faith, regardless of their licensure status in that particular state.

Choice B rationale:

Basic life support (BLS) certification is a valuable credential for performing CPR and other emergency procedures. However, the Good Samaritan law does not require the responder to have BLS certification to be protected.The law focuses more on the intent and actions of the responder rather than their specific certifications.

Choice C rationale:

The primary criterion for the Good Samaritan law to provide civil immunity is that the responder does not cause harm to the client.The law is designed to protect those who act in good faith to provide emergency care without gross negligence or willful misconduct. If the nurse’s actions are reasonable and do not result in harm, they are typically protected under the Good Samaritan law.

Choice D rationale:

Remaining with the client when traveling to the hospital in an ambulance is not a requirement for Good Samaritan law protection. The law applies to the immediate emergency care provided at the scene.Once professional medical personnel take over, the Good Samaritan law’s protection generally ends.