An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life.
The client is accompanied by a close friend, but no family members are available.
Which action should the nurse take first?
Carry on with surgical preparation of the client without a signed informed consent.
Ask the man's friend to sign the informed consent since the client is unresponsive.
Notify the unit manager that an emergency court order is needed to allow surgery.
Continue to provide life support until a thorough search for a guardian is completed.
The Correct Answer is A
The correct answer is choice a. Carry on with surgical preparation of the client without a signed informed consent.
Choice A rationale:
In emergency situations where immediate surgery is required to save a patient’s life and no family members are available, the doctrine of presumed consent applies. This means that healthcare providers can proceed with necessary treatment without a signed informed consent to prevent serious harm or death.
Choice B rationale:
Asking the man’s friend to sign the informed consent is not appropriate because friends are not legally authorized to provide consent for medical procedures unless they have legal documentation proving their authority.
Choice C rationale:
Notifying the unit manager for an emergency court order would delay the necessary surgery, which could be detrimental to the patient’s health. In emergencies, immediate action is required, and waiting for a court order is not feasible.
Choice D rationale:
Continuing to provide life support while searching for a guardian would also delay the necessary surgery. In life-threatening situations, immediate surgical intervention is prioritized over finding a legal guardian.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D rationale:
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.
Choice B rationale:
Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.
Choice C rationale:
The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.
Choice D rationale:
While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.
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