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.
None
None
The Correct Answer is A
A. In emergency situations where the client is unconscious and requires immediate life-saving surgery, implied consent is assumed. The nurse should prepare the client for surgery without waiting for family members or a formal consent process. Delaying treatment could jeopardize the client's life.
B. Contacting the ethics committee could delay the urgent care needed in an emergency situation. Immediate action should be taken in the best interest of the client.
C. Waiting for a family member to arrive could delay critical care, which may lead to worsening of the client's condition or even death.
D. The surgeon does not need to provide consent. It is the healthcare team's responsibility to act in the client's best interest when the client is unable to provide consent in an emergency.
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Related Questions
Correct Answer is D
Explanation
A. Two-point alternating gait involves partial weight-bearing on both legs and wouldn’t suit a client who can bear weight on only one leg.
B. Four-point alternating gait involves walking by moving one crutch followed by the opposite leg and is not suitable for a person who can bear weight on just one leg.
C. Swing-through gait involves swinging both legs forward between the crutches, typically used for individuals who have little or no weight-bearing ability.
D. Three-point gait involves bearing weight on one leg while using crutches and moving the other leg forward, the most appropriate gait for someone who can bear weight on one leg.
Correct Answer is C
Explanation
A. Use an 18-gauge, 1-inch needle to administer the medication:
This is incorrect because an 18-gauge needle is too large and not appropriate for subcutaneous injections like heparin. A smaller gauge needle, such as 25- to 27-gauge, and a shorter length (⅜ to ⅝ inch) is recommended for subcutaneous injections.
B. Massage the injection site after withdrawing the needle:
This is incorrect because massaging the injection site after administering heparin can increase the risk of bruising and hematoma formation. Heparin is an anticoagulant, and gentle handling of the injection site is crucial.
C. Inject 5.1 cm (2 in) away from the umbilicus:
This is correct. Heparin is administered subcutaneously, typically in the abdomen, avoiding areas near the umbilicus or scars. Injecting at least 2 inches away from the umbilicus ensures the medication is delivered to appropriate subcutaneous tissue and minimizes complications.
D. Expel air bubble before injecting medication:
This is incorrect because the air bubble in prefilled heparin syringes should not be expelled. The air bubble helps ensure the full dose is administered and reduces the risk of medication leakage.
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