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A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)
- A. Verify the client understands the surgical procedure.
- B. Validate the signature is authentic.
- C. Confirm that the consent is voluntary.
- D. Explain the surgical procedure to the client.
- E. Establish that the client is able to pay for the surgical procedure.
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Verifying the client understands the surgical procedure ensures they are informed about what will occur during surgery.
B: Validating the signature is authentic confirms the client has personally given consent, enhancing legal protection.
C: Confirming consent is voluntary ensures the client is not coerced or pressured, upholding ethical principles.
Summary:
D: Explaining the surgical procedure is important but not solely the nurse's responsibility for obtaining consent.
E: Ability to pay is not a factor in obtaining informed consent.
Overall, A, B, and C are crucial steps to ensure informed and voluntary consent.
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A nurse is caring for a client who is postoperative following a hip replacement. The client's surgical drain has minimal output. Which of the following actions should the nurse take first?
- A. Notify the provider of the minimal drain output.
- B. Flush the drain with sterile saline.
- C. Document the drain output in the medical record.
- D. Check the drain for kinks or obstructions.
Correct Answer: D
Rationale: Checking the drain for kinks or obstructions is the first step to determine if the minimal output is due to a mechanical issue, which can often be resolved without further intervention.
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?
- A. Delegation provides appropriate resources for the client.
- B. Delegation promotes discharge teaching activities for clients.
- C. Delegation permits a designated individual to meet a goal on your behalf.
- D. Delegation decreases health care costs.
Correct Answer: C
Rationale: Rationale: Answer C is correct because delegation allows a designated individual to accomplish a specific task or goal on behalf of the delegator. This ensures efficient and effective delivery of care while maximizing resources. Option A is incorrect as it refers to resource allocation, not delegation's purpose. Option B is incorrect as delegation is not solely for discharge teaching. Option D is incorrect as while delegation may contribute to cost-effectiveness, it is not its primary purpose.
A charge nurse is reviewing documentation in the medical record from a newly licensed nurse. Click to highlight the findings that indicate this nurse requires additional education.
- A. The client is inappropriate and is a huge fall risk
- B. The provider has denied this RN's requests for physical or chemical restraints
- C. They appear 'medically stable
- D. the partner is at bedside and said that their spouse is always complaining or arguing
- E. Morphine 10mg IV given orally
- F. The client has a history of major depressive disorder and alcohol use disorder
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. A indicates the nurse's lack of understanding of patient safety by not recognizing the fall risk. B suggests a lack of knowledge on restraint alternatives. C shows an inadequate assessment of the patient's overall condition. D reflects poor communication skills and lack of understanding of family dynamics. Choices E and F are not necessarily indicative of a need for additional education based on the information provided.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?
- A. Insist the client take prescribed medications.
- B. Inform the client that the medication is the same as taken at home.
- C. Tell the client that refusal of the medication is considered noncompliance.
- D. Encourage the client to verbalize questions.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to verbalize questions. This demonstrates client advocacy as it empowers the client to actively participate in their care, promotes informed decision-making, and ensures understanding of the medication. This approach respects the client's autonomy and right to make informed choices. It also allows the nurse to address any concerns or misconceptions the client may have, leading to better adherence to the treatment plan.
Incorrect choices:
A: Insisting the client take prescribed medications goes against the principles of client autonomy and informed consent.
B: Simply informing the client about the medication without addressing their questions or concerns does not actively involve the client in their care.
C: Labeling the client's refusal as noncompliance can be seen as judgmental and does not encourage open communication or shared decision-making.