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:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
Correct Answer is C
Explanation
Choice A rationale:
Wave hands to attract the attention of law enforcement. Rationale: This is not recommended during an active shooter situation. Waving hands to attract attention may draw the shooter's focus towards you. It's generally safer to stay quiet and hidden rather than trying to signal law enforcement.
Choice B rationale:
Move wounded clients to a safe area before finding shelter. Rationale: While it's important to provide assistance to wounded clients, moving them during an active shooter situation may not be advisable. It can put both the wounded and those attempting to help them at risk. The priority is to find a safe place and take cover while awaiting law enforcement.
Choice C rationale:
Turn cellular phones to silent mode. Rationale: This is the correct action to take. Turning cellular phones to silent mode helps maintain silence and prevent the phone from ringing or vibrating, potentially alerting the shooter to your location. It's essential to maintain silence and avoid drawing attention during an active shooter situation.
Choice D rationale:
Attempt to bargain with the shooter. Rationale: Attempting to bargain with the shooter is not a recommended action. Engaging with the shooter can escalate the situation and put lives at risk. The best course of action is to hide, stay quiet, and await law enforcement intervention.
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