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 A

Explanation

Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.

Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.

The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.

It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.

A. Encourage prolonged dangling before ambulation. B. Irrigate indwelling catheter with 500 mL of fluid. C. Administer an enema. D. Assist the client with a sitz bath. E. Encourage oral fluid intake.

Correct Answer is E

Explanation

Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.

The other options are not appropriate based on the information provided:

"Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
"Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
"Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
"Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is E

Explanation

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