A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?

Provide information about alternate birth control methods.

Ask if the client has discussed the decision with their partner.

Emphasize the benefits of having the procedure.

Discuss the client's feelings about the procedure.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Provide information about alternate birth control methods.

Choice A rationale:

The nurse should prioritize providing information about alternate birth control methods to the client who is uncertain about undergoing a tubal ligation. This approach aligns with the principle of informed consent and patient autonomy. By presenting different options, the client can make a well-informed decision about their reproductive health. This ensures that the client's choice is based on a comprehensive understanding of all available alternatives.

Choice B rationale:

While involving the client's partner in the decision-making process can be important, the primary responsibility of decision-making lies with the client. Therefore, asking if the client has discussed the decision with their partner (Choice B) may not directly address the client's uncertainty and need for information about alternative birth control methods.

Choice C rationale:

Emphasizing the benefits of having the procedure (Choice C) might not be appropriate if the client is uncertain about whether it's the right choice for them. This approach may come across as biased and not respectful of the client's ambivalence. Providing unbiased information about all options is a more balanced approach.

Choice D rationale:

Discussing the client's feelings about the procedure (Choice D) is essential but should be done in conjunction with providing information about alternate birth control methods. Addressing the client's emotions without offering alternatives may not fully support the client's decision-making process.

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Correct Answer is D

Explanation

Answer is: Wear an N95 respirator mask when in the client’s room.

Explanation: Pulmonary tuberculosis (TB) is a contagious disease caused by bacteria that can spread through the air. The most common way of transmission is through respiratory droplets that are expelled when a person with active TB coughs, sneezes, or speaks1. Therefore, the charge nurse should expect the newly licensed nurse to take precautions to protect themselves and the client from exposure to TB. One of these precautions is to wear an N95 respirator mask when in the client’s room2. An N95 respirator mask is a type of personal protective equipment (PPE) that filters out at least 95% of airborne particles, including bacteria and viruses3. It can prevent the nurse from inhaling or spreading TB to others.

The other options are incorrect because:

Place the client on droplet precautions: Droplet precautions are not enough to prevent transmission of TB, as they only protect against respiratory droplets that are less than 5 micrometers in diameter1. However, TB bacteria can be found in larger droplets that can travel farther and infect people who are not in direct contact with the source1.
Place the client in a room with positive-pressure airflow: Positive-pressure airflow is not effective against TB, as it does not reduce the concentration of airborne particles or prevent them from escaping through cracks and gaps in doors and windows. Moreover, positive-pressure airflow can create negative pressure in other areas of the facility, which can increase the risk of cross-contamination.
Wear a surgical mask when taking the client out of the room: A surgical mask is not sufficient to protect against TB, as it only filters out particles that are larger than 5 micrometers in diameter3. It also does not fit properly on the face and may allow some particles to pass through3.

A. Removal of staples from a surgical wound. B. Providing a sputum specimen. C. Receiving moderate sedation. D. Collection of a blood specimen for ABGS.

Correct Answer is C

Explanation

Answer is c. Receiving moderate sedation.

a. Removal of staples from a surgical wound: This procedure is typically considered routine and minimally invasive, involving the removal of staples used for wound closure. While it involves physical manipulation of the wound site, it does not carry significant risks or require the alteration of the patient's consciousness. Therefore, obtaining informed consent for this procedure is not typically necessary as it falls within the standard of care for post-operative wound management.

b. Providing a sputum specimen: Collecting a sputum specimen is a non-invasive procedure commonly performed to aid in the diagnosis of respiratory conditions such as infections or chronic lung diseases. It involves expectorating mucus from the respiratory tract, which does not pose significant risks to the patient. As such, informed consent is usually not required for this procedure since it is relatively simple and does not involve any invasive interventions or alteration of consciousness.

c. Receiving moderate sedation: Correct. Moderate sedation involves the administration of drugs, typically benzodiazepines or opioids, to induce a state of decreased consciousness and relaxation while maintaining the patient's ability to respond to verbal commands and physical stimulation. This procedure carries inherent risks, including respiratory depression, cardiovascular complications, and potential allergic reactions to the medications used. Due to the potential for adverse effects and the altered state of consciousness induced by moderate sedation, informed consent is necessary to ensure that patients understand the risks and benefits of the procedure before it is performed.

d. Collection of a blood specimen for ABGs: Arterial blood gas (ABG) analysis involves the collection of a blood sample from an artery, typically the radial artery in the wrist, to assess the patient's acid-base balance, oxygenation status, and ventilation. While this procedure does involve puncturing the skin and accessing the arterial blood supply, it is considered a standard diagnostic test in many clinical settings. However, the invasiveness of the procedure and potential risks such as bleeding, hematoma formation, and arterial injury may necessitate informed consent in certain situations, especially if the patient has underlying coagulopathies or other risk factors that could increase the likelihood of complications.

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A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Correct Answer is C

Explanation

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