A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Removal of staples from a surgical wound.

Providing a sputum specimen.

Receiving moderate sedation.

Collection of a blood specimen for ABGS.

Answer and Explanation

The Correct Answer is C

Answer is c. Receiving moderate sedation.

a. Removal of staples from a surgical wound: This procedure is typically considered routine and minimally invasive, involving the removal of staples used for wound closure. While it involves physical manipulation of the wound site, it does not carry significant risks or require the alteration of the patient's consciousness. Therefore, obtaining informed consent for this procedure is not typically necessary as it falls within the standard of care for post-operative wound management.

b. Providing a sputum specimen: Collecting a sputum specimen is a non-invasive procedure commonly performed to aid in the diagnosis of respiratory conditions such as infections or chronic lung diseases. It involves expectorating mucus from the respiratory tract, which does not pose significant risks to the patient. As such, informed consent is usually not required for this procedure since it is relatively simple and does not involve any invasive interventions or alteration of consciousness.

c. Receiving moderate sedation: Correct. Moderate sedation involves the administration of drugs, typically benzodiazepines or opioids, to induce a state of decreased consciousness and relaxation while maintaining the patient's ability to respond to verbal commands and physical stimulation. This procedure carries inherent risks, including respiratory depression, cardiovascular complications, and potential allergic reactions to the medications used. Due to the potential for adverse effects and the altered state of consciousness induced by moderate sedation, informed consent is necessary to ensure that patients understand the risks and benefits of the procedure before it is performed.

d. Collection of a blood specimen for ABGs: Arterial blood gas (ABG) analysis involves the collection of a blood sample from an artery, typically the radial artery in the wrist, to assess the patient's acid-base balance, oxygenation status, and ventilation. While this procedure does involve puncturing the skin and accessing the arterial blood supply, it is considered a standard diagnostic test in many clinical settings. However, the invasiveness of the procedure and potential risks such as bleeding, hematoma formation, and arterial injury may necessitate informed consent in certain situations, especially if the patient has underlying coagulopathies or other risk factors that could increase the likelihood of complications.

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Correct Answer is C

Explanation

Choice A rationale:

Assigning clients who have had stem cell transplants to the same room is not a recommended practice. Clients with compromised immune systems should be isolated to reduce the risk of infection transmission. Placing them together increases the potential for exposure to infectious agents.

Choice B rationale:

Obtaining a rectal temperature on clients every 4 hours is not specifically related to caring for clients following stem cell transplants. Vital sign monitoring is essential, but the frequency and method of temperature measurement can vary based on the individual client's condition and clinical judgment.

Choice C rationale:

(Correct Choice) Wearing an N95 respirator mask while caring for clients following stem cell transplants is important due to their compromised immune systems. These clients are at higher risk of infections, and N95 masks provide enhanced respiratory protection against airborne pathogens.

Choice D rationale:

Placing clients in positive-pressure airflow rooms is not a standard practice for caring for clients following stem cell transplants. Positive-pressure rooms are often used for clients with conditions like immunodeficiency, but stem cell transplant recipients are generally placed in protective isolation rooms to minimize infection risk.

A. Open the top flap of the sterile package towards the body. B. Maintain a 1.25 cm (0.5 in) border around the edges of the sterile field. C. Pick up the first sterile glove by grasping the folded cuff edge. D. Remove soiled dressings using sterile gloves.

Correct Answer is C

Explanation

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

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A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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