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 D
Explanation
Choice A rationale:
Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.
Choice B rationale:
Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.
Choice C rationale:
Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.
Choice D rationale:
Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.
Correct Answer is B
Explanation
The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.
Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.
Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.
Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.
Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.
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