A nurse is reinforcing teaching with a newly licensed nurse about informed consent. Which of the following statements should the nurse make?
"The client can revoke consent even after the procedure has begun."
"The nurse is responsible for obtaining informed consent.”
"Consent must be obtained from a family member if a client has a mental illness."
"The charge nurse will explain the risks of the procedure to the client.”
The Correct Answer is A
Rationale:
A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.
B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.
C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.
D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale
• Ensure the transfusion tubing is flushed with dextrose 5% in water: Flushing with D5W can cause hemolysis due to the hypotonicity and sugar content, leading to clumping or damage to red blood cells. Normal saline is the only acceptable fluid for flushing or administering with blood products to maintain cell integrity and avoid adverse reactions.
• Obtain a large-bore IV catheter: A large-bore catheter, typically 18–20 gauge, is necessary to allow rapid infusion of blood and reduce the risk of hemolysis. It also minimizes resistance and facilitates effective delivery during emergencies like hypovolemic shock from GI bleeding.
• Witness the client signing a consent for transfusion: Informed consent is a legal and ethical requirement prior to initiating a transfusion. The nurse must ensure that the client understands the purpose, benefits, and risks of the procedure, and the nurse may witness the client’s signature.
• Ensure two nurses confirm the information on the blood label: Verifying the client's identity and blood product information by two licensed personnel prevents transfusion errors, such as ABO incompatibility. This is a critical safety measure and a standard facility protocol before starting the transfusion.
• Explain to the client that transfusion reactions are not serious: Minimizing the risks of transfusion reactions is misleading and unsafe. Some reactions can be life-threatening, such as hemolytic or anaphylactic reactions. The nurse should provide accurate education about potential signs and encourage prompt reporting.
Correct Answer is A
Explanation
Rationale:
A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.
B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.
C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.
D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.
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