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

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.

A. Inform the staff of the penalties that can result from medication errors. B. Encourage the staff to have two nurses verify medication orders to prevent errors. C. Provide a suggestion box for the staff to submit ideas for error prevention. D. Ask three experienced nurses to help investigate common causes of the errors.

Correct Answer is A

Explanation

Choice A rationale:

Informing the staff of the penalties that can result from medication errors represents an authoritarian approach to managing the issue. This approach relies on authority and fear to enforce compliance. By emphasizing the potential consequences, the nurse manager is attempting to control behavior through fear of punishment. While this might create a short-term change in behavior, it does not address the root causes of the errors or promote a culture of safety.

Choice B rationale:

Encouraging the staff to have two nurses verify medication orders to prevent errors is not an authoritarian approach. It involves collaboration and peer support to enhance medication safety. This approach promotes shared responsibility and accountability, which are not associated with authoritarian leadership.

Choice C rationale:

Providing a suggestion box for the staff to submit ideas for error prevention is not an authoritarian approach. This strategy fosters a participative and democratic leadership style. It encourages staff engagement and input, which contrasts with the top-down nature of authoritarian leadership.

Choice D rationale:

Asking three experienced nurses to help investigate common causes of the errors is not an authoritarian approach. It involves a collaborative and problem-solving approach that seeks input from knowledgeable staff members. This approach aims to identify systemic issues contributing to errors rather than focusing solely on punitive measures.

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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?

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Naxlex Comprehensive Predictor Exams

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