A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

Proceed with preparation of the patient for the surgical procedure.

Remind the client that a signed informed consent form is a legally binding document.

Inform the surgical team to cancel the client's surgery.

Answer and Explanation

The Correct Answer is A

A reason:

Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is correct. The client's autonomy and right to refuse treatment must be respected, and the surgeon should be informed to discuss the client's concerns and possible alternatives.

B reason:

Proceeding with preparation for the surgical procedure without addressing the client's withdrawal of consent violates ethical and legal standards. The client's decision must be honored.

C reason:

Reminding the client that a signed informed consent form is legally binding is incorrect. Informed consent can be withdrawn at any time, and the client's right to change their mind must be respected.

D reason:

Informing the surgical team to cancel the surgery is not the nurse's decision alone. The nurse should first notify the surgeon to ensure that all necessary discussions and documentation occur.

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Correct Answer is D

Explanation

A reason:

Holding a sterile item at just above waist level is correct practice. This helps maintain the sterility of the item by keeping it within the sterile field and preventing it from touching non-sterile surfaces.

B reason:

Placing a sterile dressing 5 cm (2 in) from the border of the sterile field is appropriate. The edges of the sterile field (usually about 2.5 cm or 1 in) are considered non-sterile, so placing items within this boundary maintains sterility.

C reason:

Opening the sterile tray by first unfolding the flap farthest from the body is correct. This technique prevents the nurse's hands and arms from passing over the sterile contents, thus maintaining the sterility of the field.

D reason:

Opening a sterile package over the middle of the sterile field is incorrect. This action can lead to contamination as the outer packaging, which is non-sterile, could contact the sterile field.

A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.

Correct Answer is A

Explanation

A reason: Remove the catheter and insert another into a different site. If a client reports pain at the IV insertion site, it may indicate improper placement or irritation. Removing the catheter and inserting another into a different site can help alleviate the discomfort and ensure proper IV access. This is the appropriate action in response to the client's complaint.

B reason: Administer an analgesic PO. While administering an oral analgesic may help with general pain, it does not address the specific issue of pain at the IV insertion site. It is important to first ensure the IV is properly placed and not causing irritation.

C reason: Request a prescription for placement of a central venous access device. A central venous access device is not typically necessary for outpatient procedures that require only peripheral IV access. This option is overly invasive and not appropriate for the situation described.

D reason: Administer a local anesthetic. Administering a local anesthetic can provide temporary relief, but it does not address the underlying cause of the pain at the IV insertion site. Ensuring proper placement by repositioning or replacing the catheter is a more appropriate initial response.

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A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Correct Answer is D

Explanation

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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