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?
Placement of a central venous catheter.
Insertion of a nasogastric tube.
Irrigation of a wound with antibiotic solution.
Administration of an iron injection using Z-track technique.
The Correct Answer is A
Choice A rationale:
Informed consent is required for invasive procedures that carry significant risks or potential complications. Placement of a central venous catheter is an invasive procedure that involves inserting a catheter into a large vein, often in the neck, chest, or groin. It carries potential risks such as infection, bleeding, and injury to nearby structures. Therefore, informed consent is necessary before performing this procedure.
Choice B rationale:
Insertion of a nasogastric tube is an invasive procedure, but it is generally considered a routine and less risky procedure compared to others. Informed consent is typically not required for nasogastric tube insertion unless there are specific institutional policies or the client lacks decision-making capacity.
Choice C rationale:
Irrigation of a wound with antibiotic solution is a standard nursing procedure, and informed consent is not typically required for wound care unless there are specific circumstances that make it necessary, such as unusual risks or patient-specific considerations.
Choice D rationale:
Administration of an iron injection using Z-track technique is also an invasive procedure, but it is a common and well-established technique for administering intramuscular injections. Informed consent is not routinely required for this procedure unless there are specific institutional policies or the client's condition warrants it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"I will notify my doctor if the stoma starts to look purple" indicates an understanding of the importance of monitoring the colostomy site for signs of compromised blood flow or ischemia. A purple or bluish color of the stoma may suggest reduced blood supply, which is a critical concern and should be reported promptly to the healthcare provider.
Choice B rationale:
"I should expect my stool to be formed" is incorrect. In a colostomy, the type of stool output will depend on the location of the colostomy and the surgical procedure performed. Stool consistency can vary, and it may be formed or semi-formed depending on the individual and the specific situation. Expecting formed stool may not always be accurate.
Choice C rationale:
"I will no longer be able to eat nuts" is not necessarily true for all individuals with a colostomy. While some people may experience digestive difficulties with certain foods, including nuts, it is not a universal rule. Dietary restrictions should be discussed with a healthcare provider or a registered dietitian based on the individual's specific condition and needs.
Choice D rationale:
"I will irrigate the colostomy every day" is not a recommended practice for all colostomy patients. Colostomy irrigation is a procedure that may be performed by some individuals with descending or sigmoid colostomies to regulate bowel movements. However, it is not necessary or appropriate for all colostomy patients. The need for colostomy irrigation should be determined by the healthcare provider and discussed with the patient as part of their individualized care plan.
Correct Answer is C
Explanation
Choice A rationale:
Offering toileting opportunities every 1 to 2 hours is a reasonable intervention in a bladder training program, but it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.
Choice B rationale:
Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.
Choice C rationale:
Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.
Choice D rationale:
Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.
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