A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Prepare the client for surgery.

Contact the facility's ethics committee for guidance.

Keep the client stable until a family member arrives to give consent.

Obtain consent from the surgeon.

Answer and Explanation

The Correct Answer is A

A. Prepare the client for surgery: In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.

B. Contact the facility's ethics committee for guidance: Contacting the ethics committee can be helpful for guidance on how to handle consent issues in complex situations, but it might not provide a timely solution for immediate emergency situations.

C. Keep the client stable until a family member arrives to give consent: While stabilizing the client's condition is important, waiting for a family member to arrive to give consent may not be feasible in emergency situations where immediate treatment is necessary. The nurse should seek guidance from appropriate channels to determine the best course of action.

D. Obtain consent from the surgeon: Surgeons do not have the authority to provide consent for treatment on behalf of a client who is unconscious. Consent must come from a legally authorized decision-maker, such as the client themselves if they have previously provided informed consent, or a designated healthcare proxy.

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Correct Answer is B

Explanation

A. Use a trochanter roll:

A trochanter roll is a positioning device placed alongside the hip to prevent external rotation of the hip joint and maintain proper alignment of the lower extremities. While it is important for maintaining proper hip alignment, it does not specifically address preventing plantar flexion contractures.

B. Use foot splints.

Plantar flexion contractures occur when the muscles and tendons in the foot and ankle become shortened, leading to a fixed downward pointing of the foot. Foot splints are devices designed to maintain the foot in a neutral position, preventing the development of contractures by keeping the ankle dorsiflexed. They help stretch the muscles and tendons in the foot and ankle, preventing them from becoming shortened over time.

C. Apply an abduction pillow to the legs:

An abduction pillow is a positioning device used to maintain proper hip alignment and prevent adduction of the hips and knees. While it is essential for preventing hip contractures and maintaining hip alignment, it does not directly address preventing plantar flexion contractures.

D. Prop the feet up:

Elevating the feet may be beneficial for improving circulation and reducing swelling, but it does not specifically address preventing plantar flexion contractures. In fact, prolonged elevation of the feet without proper support may increase the risk of developing contractures by allowing the foot to remain in a plantar flexed position for extended periods.

A. Give the client's medications between meals. B. Assist the client into semi-Fowler's position. C. Encourage the client to use a straw to take the medication D. Administer the client's medications one at a time

Correct Answer is D

Explanation

A. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.

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A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?

Correct Answer is B

Explanation

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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