A nurse is speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?

Ask the client's partner to sign as next of kin.

Document the client's refusal in their medical record.

Check to see if the client has an advance directive.

Ask the provider to explain the procedure through an interpreter.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Ask the client's partner to sign as next of kin: The partner cannot legally provide informed consent on behalf of the client unless they have legal power of attorney. Consent must come from the client unless they are incapacitated.

B. Document the client's refusal in their medical record: While documentation is important, it should only occur after ensuring the client fully understands the procedure. Without effective communication, refusal may not be informed.

C. Check to see if the client has an advance directive: Advance directives guide care if the client is incapacitated but may not apply if the client is alert and able to make decisions about the current procedure.

D. Ask the provider to explain the procedure through an interpreter: Using a professional interpreter ensures clear communication so the client can make an informed decision about the cesarean birth, respecting autonomy and reducing misunderstanding.

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Correct Answer is A

Explanation

Rationale:

A. Encourage client to swallow while advancing tube: Swallowing facilitates the passage of the nasogastric tube through the oropharynx and esophagus by closing the epiglottis and reducing the risk of the tube entering the trachea. This action helps guide the tube smoothly into the stomach.

B. Measure the length of the tube from client's nose to shoulder: Proper measurement involves extending the tube from the nose to the earlobe and then down to the xiphoid process, not just to the shoulder.

C. Place client in semi-Fowler's position in bed: The client should be placed in a high-Fowler’s position, not semi-Fowler’s, to promote comfort and reduce the risk of aspiration. This upright position also allows for easier passage of the tube through the upper GI tract.

D. Advance tube during client's inspiration: Advancing the tube during inspiration increases the risk of the tube entering the airway rather than the esophagus. The tube should be advanced when the client is swallowing, which helps direct it into the digestive rather than respiratory tract.

A. Tilt the client's head forward during meals. B. Encourage socialization during meal times. C. Elevate the head of the client's bed to 30", D. Provide three large meals per day.

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

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A nurse is speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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