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.
Obtain consent from the surgeon.
Contact the facility's ethics committee for guidance.
Keep the client stable until a family member arrives to give consent.
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. Obtain consent from the surgeon:
The surgeon is not the appropriate person to obtain consent from in this situation. Informed consent should ideally come from the client or a legal surrogate decision-maker, depending on the circumstances. Surgeons are responsible for discussing the procedure with the patient or their authorized representative before surgery, but obtaining consent is not the nurse's role.
C. Contact the facility's ethics committee for guidance:
While the ethics committee may provide guidance in complex ethical situations, the immediate concern in this emergency situation is to address the client's life-threatening condition. The nurse should prioritize actions that ensure the client receives timely and necessary medical care.
D. Keep the client stable until a family member arrives to give consent:
While obtaining consent from a family member is ideal, waiting for consent can delay critical and time-sensitive interventions. In emergency situations, the priority is to provide necessary medical care promptly to stabilize the client. If there is no one available to give consent immediately, healthcare providers may proceed with necessary interventions to preserve life and limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
Correct Answer is D
Explanation
A. A feeling of swelling in the feet:
Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.
B. Pain at the injection site:
Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.
C. A sudden decrease in heart rate:
An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.
D. A sharp decrease in blood pressure:
This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.
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