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 B
Explanation
Choice A rationale:
Encourage the client to have continual bed rest. Rationale: Continual bed rest is not the appropriate intervention for a client experiencing chronic fatigue due to leukemia. Prolonged bed rest can lead to further weakness and deconditioning. Encouraging some level of physical activity, such as gentle exercise, can help improve strength and reduce fatigue.
Choice B rationale:
Encourage strength-training exercise. Rationale: This is the correct intervention for a client with leukemia experiencing chronic fatigue. Strength-training exercises, when appropriate and under the guidance of healthcare professionals, can help improve muscle strength and overall endurance. It can combat the fatigue commonly associated with leukemia and its treatment.
Choice C rationale:
Increase the client's fluids to 4 L per day. Rationale: While adequate hydration is essential, increasing fluids to 4 liters per day may not be appropriate for every client. The optimal fluid intake for a client should be determined based on their individual needs and medical condition. Excessive fluid intake without medical indication can lead to complications like fluid overload.
Choice D rationale:
Increase protein in the diet. Rationale: Increasing protein intake can be beneficial for clients with leukemia as it helps in tissue repair and supports the immune system. However, it should be done in consultation with a registered dietitian to ensure that the client's specific dietary needs are met.
Correct Answer is B
Explanation
Choice A rationale:
Hospice care is typically recommended for clients with a terminal illness who are no longer seeking curative treatment. It may not be suitable for an older adult with early onset dementia unless their condition is very advanced.
Choice B rationale:
Recommending an adult day care facility is appropriate in this situation. Adult day care centers provide a safe and stimulating environment for older adults who require supervision and socialization during the day. It can be a helpful resource for the client's care while the adult child is at work.
Choice C rationale:
Suggesting a community senior center is a good option for social engagement and activities, but it may not provide the level of supervision and care needed for an older adult with dementia, especially if the adult child works full-time.
Choice D rationale:
Recommending a long-term care facility is a more drastic step and is typically considered when a client's care needs cannot be met at home or in less restrictive settings. It may not be necessary for a client with early onset dementia who still has family support.
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