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 ["C","D","E"]
Explanation
Rationale:
A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.
B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.
C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.
D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.
E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.
Correct Answer is B
Explanation
Rationale:
A. Arterial blood gases: While ABGs assess respiratory and metabolic balance, they are not routinely monitored for clients on furosemide. This test is more relevant for clients with severe respiratory or acid-base disorders, not as a direct indicator of diuretic therapy effects.
B. Blood urea nitrogen: Furosemide is a loop diuretic that can affect kidney function by reducing circulating blood volume. Monitoring BUN helps assess renal perfusion and detect early signs of dehydration or nephrotoxicity associated with diuretic use.
C. Prothrombin time: PT evaluates coagulation status, typically in clients taking anticoagulants like warfarin. Furosemide does not affect clotting pathways, so PT monitoring is unnecessary in this context unless the client is on anticoagulants for another condition.
D. Thyroid stimulating hormone: TSH measures thyroid function but is not influenced by furosemide. There is no established link between furosemide and thyroid activity that would necessitate routine TSH monitoring for clients taking this medication.
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