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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.
Choice B rationale:
The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.
Choice C rationale:
The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.
Choice D rationale:
The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.
Correct Answer is A
Explanation
The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.
Choice A rationale:
The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.
Choice B rationale:
Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.
Choice C rationale:
The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.
Choice D rationale:
The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.
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