An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?
Ask the client'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.
Carry on with surgical preparation of the client without a signed informed consent.
Continue to provide life support until a thorough search for a guardian is completed.
The Correct Answer is C
Rationale
A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.
B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.
C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.
D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Client A's oxygen saturation is acceptable for someone with emphysema.
B. This is because Client B's postoperative hemoglobin level is 8.2 mg/dL, which is significantly lower than the normal reference range of 14 to 18 g/dL. This indicates that Client B is anemic and may require a blood transfusion to increase the hemoglobin level.
C. Client C's potassium level is within the normal range
D. Client D's WBC count is elevated, moving them into isolation is not indicated solely based on an elevated WBC count.
Correct Answer is ["A","B","D","G","H"]
Explanation
A. Assessing temperature is important to monitor for any signs of infection or inflammation, which could exacerbate the asthma condition or indicate a concurrent illness.
B. Evaluating breath sounds helps determine the effectiveness of the albuterol treatment in relieving bronchospasm. Clearer breath sounds suggest improved air entry and reduced wheezing.
C. While CBC can provide valuable information, it is not typically immediately necessary after an albuterol treatment unless there are specific concerns about infection or other systemic issues.
D. Monitoring the heart rate is crucial as albuterol can cause tachycardia (elevated heart rate) as a side effect. It's important to ensure that the heart rate does not become excessively elevated, which may indicate a need to adjust treatment or monitor more closely.
E. Peak inspiratory flow is less commonly used in asthma management compared to peak expiratory flow. It's the maximum flow rate during inhalation and is not typically assessed routinely in the immediate post-treatment period.
F. Assessing serum sodium is not directly related to monitoring asthma exacerbation or response to bronchodilator therapy.
G. PEF measures the maximum speed at which a person can exhale air after a deep breath. It is a direct indicator of lung function and the severity of airway obstruction in asthma. Assessing PEF post-albuterol treatment helps gauge how well the airways have responded to the bronchodilator therapy.
H. Checking oxygen saturation ensures that the patient's oxygen levels have improved following the administration of albuterol. The goal is to maintain oxygen saturation above 94%, as per the treatment plan.
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