A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Irrigation of a wound with antibiotic solution

Insertion of a nasogastric tube

Placement of a central venous catheter

Administration of an iron injection using Z-track technique

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B.   Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C.   Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D.   Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.

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Correct Answer is A

Explanation

A. Correct. This situation involves a potential medication error due to the electronic IV pump delivering excessive fluid, which requires documentation and an incident report for reporting and tracking purposes.
B. While observing another nurse's practice is important, the scenario does not involve an incident that requires reporting via an incident report.
C. This situation may warrant a medication incident report, but the family member's administration of PCA might be within their scope if properly trained and authorized.
D. This scenario involves a side effect of a medication, but it is not a situation requiring an incident report unless it is a severe or unexpected reaction.

A. Ask the client if they would like to watch television. B. Use short, simple sentences when speaking with the client. C. Allow the client to have 1 hr of time alone in their room. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

A. Incorrect. Offering to watch television may not address the client's agitation and anxiety effectively.
B. Correct. The client's behaviors suggest anxiety or agitation. Using short, simple sentences when speaking with the client can help reduce their stress and facilitate communication.
C. Incorrect. While some clients may benefit from alone time, it's important to assess the client's preferences and needs. Isolating the client in their room might not be the best approach if they are seeking engagement.
D. Incorrect. Moving the client to a group setting may increase their discomfort or agitation. It's important to consider the client's current emotional state and tailor interventions accordingly.

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A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

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