A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

Obtain telephone consent from the facility administrator before the surgery.

Delay the surgery until the nurse can obtain informed consent.

Ask the anesthesiologist to sign the consent.

Transport the client to the operating room without verifying informed consent.

Answer and Explanation

The Correct Answer is D

A.   Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B.   Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C.   Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D.   Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.

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Correct Answer is B

Explanation

A. Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B. Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C. Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D. Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.

A. Is the client's family present so the AP can show them how to turn the client? B. Has the AP checked the client's pain level prior to turning her? C. Does the AP have time to change the client's central IV line dressing after turning her? D. Has data been collected about specific client needs related to turning?

Correct Answer is D

Explanation

A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

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A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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