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

Administration of an iron injection using Z-track technique

Placement of a central venous catheter

Insertion of a nasogastric tube

Answer and Explanation

The Correct Answer is C

Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.

Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.

Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.

The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.

Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.

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Correct Answer is C

Explanation

Explanation

C. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.

A. Posterior fontanel closed B. Rolls from back to abdomen C. Anterior fontanel closed D. Moves objects to mouth

Correct Answer is C

Explanation

Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.

The other findings mentioned are typical developmental milestones for a 4-month-old infant:

Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is C

Explanation

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

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