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 B

Explanation

Rationale:

A. Occupational therapist: An occupational therapist helps clients regain skills for daily living and can assess driving ability, but they are not typically responsible for arranging transportation or addressing confidence-related psychosocial issues. A referral may follow but is not the first step here.

B. Social worker: A social worker assists clients with coping and resource coordination, including transportation services, community support, and addressing emotional or confidence barriers. This makes them the most appropriate referral when a client is unsure about attending follow-up care.

C. Primary care provider: While the PCP oversees general medical care and referrals, they are not responsible for coordinating transportation. The nurse can directly initiate a more appropriate referral rather than relying on the PCP for this non-medical concern.

D. Physical therapist: A physical therapist focuses on improving physical function, mobility, and strength. They do not handle transportation issues or confidence concerns related to attending appointments, making them less relevant in this context.

A. Home telephone number B. Medical diagnosis C. Date of admission D. Facility room number

Correct Answer is A

Explanation

Rationale:

A. Home telephone number: A home telephone number is an acceptable second client identifier under The Joint Commission's guidelines, as it is specific to the individual and can help prevent medication errors when used alongside another unique identifier.

B. Medical diagnosis: A medical diagnosis is not a unique identifier and may be shared by multiple clients in the same facility. It does not provide adequate confirmation of a client's individual identity.

C. Date of admission: Admission dates are not unique and may be the same for several clients. This information is insufficient as a reliable identifier for ensuring safe medication administration.

D. Facility room number: Room numbers can change during hospitalization and are not considered safe identifiers. Clients may be transferred, making room number an unreliable and non-permanent method of identification.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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