A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

Ask the client to sign the consent form anyway.

Notify the charge nurse about the situation.

Remind the client about the specifics of the procedure.

Explain to the client that the procedure will help treat his diagnosis

Answer and Explanation

The Correct Answer is B

The correct answer is B. Notify the charge nurse about the situation. Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions.

The nurse should not ask the client to sign the consent form anyway (A), as this would violate the patient's right to autonomy and self-determination.

The nurse should not remind the client about the specifics of the procedure (C) or explain to the client that the procedure will help treat his diagnosis (D), as these are not within the nurse's scope of practice and may be considered as giving medical advice.

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Correct Answer is C

Explanation

The correct answer is C. Observe the client during and after meals. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The nurse should monitor the client for signs of purging, such as frequent trips to the bathroom, and provide support and supervision during and after meals to prevent this behavior . This is a priority intervention that addresses the client's physical health and safety.

A. Discard the first 10 mL of urine. B. Don sterile gloves prior to the procedure. C. Obtain a 12-French catheter. D. Apply EMLA cream prior to the procedure.

Correct Answer is B

Explanation

Choice A reason:

Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.

Choice B reason

Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.

Choice C reason

The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.

Choice D reason

EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.

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A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?

Correct Answer is B

Explanation

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