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The nurse manager is developing an educational session for nursing staff on the components of informed consent and the information to be shared with a client to obtain informed consent. Which information should the nurse manager include in the session? Select all that apply.
- A. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused.
- B. The client cannot refuse a test, procedure, or treatment once the test, procedure, or treatment is started.
- C. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form.
- D. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.
- E. The nurse is responsible for obtaining the client's signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.
Correct Answer: A,C,D
Rationale: Informed consent is a person's agreement to allow something to happen based on full disclosure of risks, benefits, alternatives, and consequences of refusal. The primary health care provider (HCP) is responsible for conveying information and obtaining the informed consent. The nurse may be the person who actually ensures that the client signs the informed consent form; however, the nurse does this only after the HCP has instructed the client, and it has been determined that the client has understood the information. The following factors are required for informed consent: a brief, complete explanation of the test, procedure, or treatment; names and qualifications of persons performing and assisting in the test, procedure, or treatment; a description of the complications and risks, as well as anticipated pain or discomfort; an explanation of alternative therapies to the proposed test, procedure, or treatment, as well as the risks of doing nothing; and the client's right to refuse the test, procedure, or treatment even after it has been started.
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Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain the specimen early in the morning.
- C. Have the client brush his teeth before expectoration.
- D. Instruct the client to take deep breaths before coughing.
- E. Place the lid of the culture container face down on the bedside table.
Correct Answer: A,B,C,D
Rationale: The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings.
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care?
- A. Providing a consistent caregiver
- B. Protecting the toddler from injury
- C. Adapting the toddler to the hospital routine
- D. Allowing the toddler to participate in play and diversional activities
Correct Answer: B
Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.
The nurse receives a telephone call from a client who states that he wants to kill himself and has a loaded gun on the table. Which intervention best assures the client's safety?
- A. Encouraging him to unload the gun and go to the hospital
- B. Telling the client that suicide is not the way to deal with his problem
- C. Using therapeutic communication techniques, especially the reflection of feelings
- D. Engaging the client while another staff member contacts the police for their assistance
Correct Answer: D
Rationale: In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A loaded gun in the home of the client who says that he wants to kill himself is a crisis. The client's safety is of prime concern. Keeping the client on the phone and getting help to the client is the best intervention. Option 1 lacks the authoritative action stance of securing the client's safety. Option 2 is not a helpful strategy and may block communication. Using therapeutic communication techniques is important, but overuse of reflection may sound uncaring or superficial and is lacking direction and a solution to the immediate problem of the client's safety.
The nurse is observing a client using a walker. Which observation by the nurse should determine that the client is using the walker correctly?
- A. Puts weight on the hand pieces, slides the walker forward, and then walks into it
- B. Puts weight on the hand pieces, moves the walker forward, and then walks into it
- C. Puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it
- D. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor
Correct Answer: C
Rationale: To use a walker correctly, the client should place all four points of the walker flat on the floor to ensure stability, then put weight on the hand pieces to support their body, and finally walk into the walker. This sequence ensures the walker remains stable and provides maximum support. Option 1 is incorrect because sliding the walker can cause instability. Option 2 is incorrect because moving the walker forward without ensuring all points are flat may lead to tipping. Option 4 is incorrect because walking into the walker before placing it flat reverses the proper sequence and compromises safety.