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:

Soft bowel sounds at a rate of 1 per minute describe hypoactive bowel sounds, which indicate decreased motility. This choice does not describe hyperactive bowel sounds.

Choice B rationale:

High-pitched bowel sounds are characteristic of hyperactive bowel sounds. These sounds are associated with increased motility and can indicate conditions such as diarrhea or early bowel obstruction. This choice correctly describes hyperactive bowel sounds.

Choice C rationale:

The absence of bowel sounds after listening for 3 to 5 minutes is indicative of absent or hypoactive bowel sounds, not hyperactive bowel sounds.

A. Increase the client's intake of oral fluids. B. Instruct the client to cough every 4 hr. C. Maintain the client in high-Fowler's position. D. Encourage the client to ambulate to loosen secretions.

Correct Answer is C

Explanation

Choice A rationale:

Increasing the client's intake of oral fluids may not address the underlying issue of crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. This client likely has fluid accumulation in the lungs, and simply increasing fluid intake could exacerbate the problem. It's important to assess and manage the client's fluid balance carefully.

Choice B rationale:

Instructing the client to cough every 4 hours may not be sufficient for managing the client's symptoms, especially if there is fluid in the lungs. Coughing alone may not adequately clear the airways. More intensive interventions are needed.

Choice C rationale:

The correct action is to "Maintain the client in high-Fowler's position." High-Fowler's position helps improve lung expansion and oxygenation by allowing the client to sit up at an angle, which reduces pressure on the diaphragm and improves lung mechanics. This position can help alleviate symptoms such as crackles and shortness of breath in clients with heart failure.

Choice D rationale:

Encouraging the client to ambulate to loosen secretions may not be appropriate in this case. Ambulation is generally encouraged for clients with adequate oxygenation and mobility. If the client has severe respiratory distress, it's crucial to address that issue first before considering ambulation.

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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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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?