A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.
Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

The correct answer is:

Choice C: Determine the medical needs of incoming clients through the emergency department.

Here's a breakdown of the rationale for each choice:

Choice A rationale: While calling in additional staff might be helpful in the long run, during the initial surge of patients in a mass casualty event, the Emergency Department (ED) will be the primary area receiving and triaging patients. The medical-surgical unit will likely receive overflow patients after initial stabilization in the ED.

Choice B rationale: This is not a primary responsibility for a nurse on a medical-surgical unit during a mass casualty event. Communication with the media is usually handled by designated public relations personnel.

Choice C rationale: This is the most crucial action for a nurse in this situation. Triaging patients based on the severity of their injuries and prioritizing care is essential in a mass casualty scenario. Nurses will be instrumental in assessing incoming patients relayed from the ED to determine their medical needs and allocate resources accordingly.

Choice D rationale: Discharging patients is not a priority during the initial influx of casualties. The focus is on receiving, stabilizing, and treating the most critically injured patients. Discharges would likely happen after the initial surge subsides.

A healthcare surrogate is a person who is authorized to make healthcare decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.
Choice A is wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.
Choice B is wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate.

The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.
Choice C is wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.
The provider is responsible for determining the medical necessity of the surgery and explaining it to the surrogate. The nurse should not question or interfere with the provider’s judgment unless there is evidence of negligence or malpractice.