A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?
Obtain consent from the client.
Acknowledge the client and sign the consent.
Obtain consent from a relative of the client.
Delay the procedure.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should intervene when the AP tears a document with client information in half before disposing of it in a waste basket. This is because client information is confidential and should be disposed of properly to protect the client's privacy. Tearing a document in half is not sufficient to ensure that the information is protected.
Option A is incorrect because logging off the computer after entering a client's intake and output totals is an appropriate action.
Option C is incorrect because denying a request by another AP to use her password to enter the client's vital signs is an appropriate action to protect the client's information.
Option D is incorrect because removing a clipboard with client information from the room during visiting hours may be necessary to protect the client's privacy.
Correct Answer is A
Explanation
If a nurse manager notices that a nurse who has a history of being resistant to change is not delivering care according to a new policy, the appropriate action for the nurse manager to take is to encourage the nurse to verbalize the reasons for their resistance to the change. This will allow the nurse manager to understand the nurse's concerns and work with them to address any issues and facilitate their acceptance of the new policy.
Option B is incorrect because ignoring the resistance and allowing peer pressure to facilitate a change in the nurse's behavior is not an effective or respectful way to address the issue.
Option C is incorrect because explaining the importance and rationale of implementing the new policy to the nurse may be necessary, but it should not be the first action taken.
Option D is incorrect because indicating that there will be disciplinary consequences if the nurse does not implement the new policy may be necessary, but it should not be the first action taken.
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