A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

Convey the client's request to the nurse who witnessed the consent.

Notify the provider about the client's concerns.

Explain the risks of the procedure to the client.

Check to see if the medical record indicates the provider explained the procedure to the client.

Answer and Explanation

The Correct Answer is B

A. Convey the client's request to the nurse who witnessed the consent. The nurse who witnessed the consent does not have the authority to explain the risks of the procedure. Their role is only to witness that the consent was signed, not to provide information about the procedure.

B. Notify the provider about the client's concerns. The provider who is performing the cardiac catheterization is legally responsible for explaining the risks, benefits, and alternatives of the procedure. If the client expresses concerns or appears to lack understanding just before the procedure, the nurse should notify the provider so they can further explain the risks and clarify any questions.

C. Explain the risks of the procedure to the client. While the nurse can offer general information about the procedure, only the provider who is performing the procedure should explain the specific risks associated with it.

D. Check to see if the medical record indicates the provider explained the procedure to the client. Even if documentation indicates that the provider previously explained the procedure, the client still has the right to have their concerns addressed by the provider just before the procedure.

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Correct Answer is D

Explanation

Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.

A. "I will wear a cover gown when caring for a client who has herpes simplex." B. "I will place a client who requires protective isolation in a negative airflow room." C. "I will wear an N95 respirator mask when caring for a client who is on contact precautions." D. "I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile."

Correct Answer is A

Explanation

Choice A Reason:
Herpes simplex virus (HSV) requires contact precautions when there are active lesions. Wearing a cover gown helps prevent the transmission of the virus through direct contact with the client or contaminated surfaces, indicating proper understanding of isolation guidelines.

Choice B Reason:
Protective isolation (also known as reverse isolation) is used for clients who are immunocompromised, and they require a positive airflow room, not a negative airflow room. Positive airflow rooms help keep contaminants out, while negative airflow rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
An N95 respirator mask is required for airborne precautions (e.g., for tuberculosis, measles, or varicella) rather than contact precautions. Contact precautions generally involve wearing gloves and a gown, but an N95 mask is not necessary.

Choice D Reason:
For clients with Clostridium difficile (C. difficile) infection, soap and water must be used for hand hygiene, not alcohol-based hand cleansers. Alcohol-based hand sanitizers are not effective against C. difficile spores, so proper handwashing with soap and water is essential to prevent the spread of this infection.

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A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

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