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?

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

Delay the surgery until the nurse can obtain informed consent.

Obtain telephone consent from the facility administrator before the surgery.

Ask the anesthesiologist to sign the consent.

Answer and Explanation

The Correct Answer is A

A. In emergency situations where immediate surgery is required to preserve life or prevent serious harm, and the client is unconscious and unable to provide consent, treatment may proceed without informed consent under implied consent.
B. Delaying surgery to obtain consent could jeopardize the client’s life or outcome, and is not ethically or legally appropriate in a true emergency.
C. Telephone consent from a facility administrator is not a substitute for legal consent. Administrators are not authorized to give medical consent for clients.
D. The anesthesiologist cannot legally provide consent on behalf of the client; this would be a breach of ethical and legal standards.

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Correct Answer is C

Explanation

A. Used to illustrate processes or workflows, not to measure outcomes. They help visualize steps in a procedure or identify where problems might occur.
B. Also known as fishbone diagrams, these are used to identify possible causes of a problem, not to measure outcomes.
C. Clinical indicators are measurable items that reflect the quality of care and are used to evaluate outcomes in quality improvement projects. Examples include infection rates, readmission rates, and patient satisfaction scores.
D. SBAR (Situation, Background, Assessment, Recommendation) is a structured communication method, not a tool for measuring

A. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 B. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood C. An older adult client who has dyspnea and a respiratory rate of 26/min D. An adult client who has large ecchymoses on both legs

Correct Answer is C

Explanation

A.An ankle injury with pain is painful but not life-threatening. This client can safely wait.
B.A 2 cm head laceration with dark red blood suggests venous bleeding and is not emergent unless signs of more serious head injury are present.
C.An older adult client with dyspnea and a respiratory rate of 26/minshould be examined first. Dyspnea (shortness of breath) and elevated respiratory rate indicate possible respiratory distress or a life-threatening condition such as pulmonary embolism, heart failure, or pneumonia. Airway and breathing issues always take priority.
D.Ecchymoses (bruising) could suggest a bleeding or clotting disorder but are not immediately life-threatening without other symptoms.

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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?

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