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.
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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Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.
Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.
Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.
Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.
Correct Answer is D
Explanation
Choice A rationale:
A nurse cannot provide basic treatment information to the client's employer without the client's explicit consent. This information falls under the client's confidentiality rights and cannot be shared without proper authorization.
Choice B rationale:
While a nurse can inform the client about the risks and benefits of electroconvulsive therapy, this statement does not encompass the entirety of the client's rights. Clients have the right to be informed about the risks and benefits of all treatments, not just electroconvulsive therapy.
Choice C rationale:
Clients on a mental health unit who are admitted voluntarily have the right to leave against medical advice, as long as they are deemed capable of making that decision. Voluntary admission does not negate a client's autonomy to make decisions about their own care.
Choice D rationale:
The correct answer. Clients on a mental health unit have the right to refuse their medication, as long as they are deemed competent to make that decision. This is an important aspect of respecting a client's autonomy and informed consent, even in a mental health setting. However, if a client's refusal poses a serious risk to their health or the health of others, healthcare providers may need to take appropriate actions while respecting legal and ethical standards.
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