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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.
B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.
C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.
D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.
Correct Answer is B
Explanation
Rationale:
A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.
B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.
C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.
D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.
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