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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.

Choice B rationale:

Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.

Choice C rationale:

Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.

Choice D rationale:

Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.

A. Temperature of 39°C (102.2°F) B. History of cigarette smoking. C. Patient reports they feel that they are going to pass out. D. Hypoglycemia.

Correct Answer is C

Explanation

Choice A rationale:

Temperature of 39°C (102.2°F) A temperature of 39°C (102.2°F) is elevated, but it is not directly related to a heart rate of 44/min. Elevated temperature can be caused by various factors, such as infection, and would not be an expected finding solely due to the heart rate.

Choice B rationale:

History of cigarette smoking. A history of cigarette smoking may be a risk factor for certain cardiovascular conditions, but it does not directly explain a heart rate of 44/min. The heart rate can be influenced by factors such as medications, cardiac conditions, and autonomic nervous system activity.

Choice D rationale:

Hypoglycemia. Hypoglycemia (low blood sugar) can cause various symptoms, including shakiness, confusion, and sweating, but it is not the primary cause of a heart rate of 44/min. Hypoglycemia is more likely to cause symptoms related to altered mental status and autonomic nervous system activation.

Choice C rationale:

Patient reports they feel that they are going to pass out. A heart rate of 44/min is significantly lower than the normal range for adults, which is typically between 60-100 beats per minute. Such a low heart rate, known as bradycardia, can lead to decreased blood flow to vital organs, including the brain. Feeling like they are going to pass out is a concerning symptom associated with bradycardia because it suggests inadequate cardiac output and perfusion. This finding should prompt immediate assessment and intervention to address the underlying cause of the slow heart rate.

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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

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Correct Answer is B

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Correct Answer is C

Explanation

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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?