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 A

Explanation

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.

A. "I should use the cap during my menstrual cycle to prevent pregnancy.” B. "I should avoid using spermicide with the cervical cap.” C. "I need to have my provider check the size of the cap every 6 months.” D. "I need to keep the cap in place for at least 6 hours after intercourse.”

Correct Answer is D

Explanation

Choice A rationale:

"I should use the cap during my menstrual cycle to prevent pregnancy." Rationale: This statement is incorrect. The cervical cap should be used only during sexual intercourse to prevent pregnancy, not during the menstrual cycle. It does not provide protection against sexually transmitted infections (STIs) and should be used in conjunction with a spermicide for effectiveness.

Choice B rationale:

"I should avoid using spermicide with the cervical cap." Rationale: This statement is incorrect. To enhance the effectiveness of the cervical cap, it should be used with a spermicide. Spermicide helps immobilize and kill sperm, providing an additional barrier against pregnancy.

Choice C rationale:

"I need to have my provider check the size of the cap every 6 months." Rationale: This statement is incorrect. While it's important for the healthcare provider to properly fit the cervical cap initially, it does not require routine sizing checks every six months. However, clients should periodically check the cap for any signs of damage or deterioration.

Choice D rationale:

"I need to keep the cap in place for at least 6 hours after intercourse." Rationale: This is the correct statement. To ensure the effectiveness of the cervical cap, it should be left in place for at least six hours after intercourse. It provides a barrier that prevents sperm from reaching the cervix. However, it should not be left in place for more than 48 hours to reduce the risk of toxic shock syndrome.

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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

A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

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?