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 D

Explanation

The correct answer is: d. Location of the identification tag on the client’s body.

Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.

Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.

Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.

Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.

A. Position the client supine with legs elevated. B. Measure the client's abdominal girth daily. C. Restrict the client's sodium intake to 3g per day. D. Keep the client's daily protein intake below 0.8 g/kg.

Correct Answer is B

Explanation

Choice A rationale:

Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.

Choice C rationale:

Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.

Choice D rationale:

Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.

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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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Correct Answer is B

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?