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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C: Increase rate of ventilation.

Choice A rationale:

Decreasing expiratory flow time would not directly address the elevated PaCO2 levels. This intervention is more related to managing expiratory phase issues rather than correcting respiratory acidosis.

Choice B rationale:

Decreasing expiratory pressure might help with certain ventilation issues, but it does not specifically target the elevated PaCO2 and resulting acidosis.

Choice C rationale:

Increasing the rate of ventilation helps to blow off more CO2, thereby reducing PaCO2 levels and correcting the respiratory acidosis indicated by the pH of 7.26 and PaCO2 of 68 mm Hg.

Choice D rationale:

Increasing the ventilator tidal volume could also help reduce PaCO2 by increasing the amount of air exchanged with each breath. However, increasing the rate of ventilation is generally a more immediate and effective intervention for acute respiratory acidosis.

A. Concerns about parenting. B. Cultural practices related to childbearing. C. Complications associated with childbirth. D. Knowledge about labor and delivery.

Correct Answer is D

Explanation

Choice A rationale:

Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.

Choice B rationale:

Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.

Choice C rationale:

Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.

Choice D rationale:

Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

Correct Answer is D

Explanation

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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?