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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.
Incorrect:
B- Limit documentation to subjective information: This is an incorrect action to take.
Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.
C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.
D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.
Correct Answer is B
Explanation
Explanation
B. Wipe any excess medication from the inner canthus outward
Bacitracin ophthalmic ointment is an antibiotic medication commonly used to treat bacterial eye infections such as conjunctivitis.
Wiping any excess medication from the inner canthus outward, is important to prevent the accumulation of excessive ointment, which can cause discomfort and affect vision. Using a clean, sterile cotton ball or tissue, the nurse should gently wipe any excess ointment from the inner corner of the eye (inner canthus) and then move outward to remove the excess ointment.
Gently massaging the eyelid to facilitate absorption of the medication in (option A) is not recommended. It can potentially cause discomfort or further irritation to the affected eye, especially in a young child. The ointment will naturally spread across the eye as the child blinks.
Placing an occlusive dressing on the affected eye in (option C) is not necessary for the treatment of bacterial conjunctivitis. It may impede proper air circulation and potentially worsen the infection. It is important to promote hygiene and prevent the spread of infection by encouraging proper handwashing and avoiding touching or rubbing the affected eye.
Instructing the guardian to apply erythromycin ophthalmic ointment every morning for 14 days in (option D) is not appropriate in this case. Erythromycin is an alternative antibiotic commonly used for conjunctivitis, but since the child has been prescribed bacitracin ophthalmic ointment, the appropriate course of treatment would be to follow the prescribed medication as directed by the healthcare provider.
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