A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

Proceed with treatment without obtaining written consent.

Contact the client's next of kin to obtain consent for treatment.

Notify risk management before initiating treatment.

Have the client sign a consent for treatment.

Answer and Explanation

The Correct Answer is A

Rationale:
A. In emergency situations where the client is unable to provide informed consent (disoriented) and there is a life-threatening condition (cardiac arrhythmia), treatment should proceed under the principle of implied consent to save life or prevent serious harm.
B. Contacting next of kin may cause a delay in critical treatment and is not required in emergencies.
C. Notifying risk management is unnecessary and would delay care.
D. The client is disoriented and unable to legally sign consent, so this option is not appropriate.

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Correct Answer is ["A","B","E","F","H","I"]

Explanation

Rationale:
A. Hydration status: Nausea, vomiting, and limited oral intake put the client at risk for dehydration, requiring monitoring and possible intervention.
B. Heart rate: Increased from 80/min at 1730 to 102/min at 2300, indicating possible systemic stress or dehydration.
E. Headache: Client reports a severe headache (7/10), which can indicate systemic worsening or complications.
F. Temperature: Rose to 39° C (102.2° F), showing worsening infection.
H. Emesis: Client vomited 230 mL, which can contribute to fluid and electrolyte imbalance.
I. Blood pressure: Increased from 118/72 mm Hg to 152/92 mm Hg, suggesting possible stress response, pain, or early complications.

A. A client who is postoperative following a thyroidectomy reports facial numbness. B. A client who has acute pyelonephritis reports pain with voiding. C. A client who has diabetes mellitus requires teaching on the self-administration of insulin. D. A client who is preoperative for a colon resection has clear liquid stools.

Correct Answer is A

Explanation

Rationale:
A. Facial numbness after a thyroidectomy suggests hypocalcemia, likely due to parathyroid gland injury, and places the client at risk for laryngeal spasms and airway obstruction. This is the priority client.
B. Pain with voiding from acute pyelonephritis is important but not immediately life-threatening.
C. Teaching about insulin administration is necessary but not urgent compared to airway compromise.
D. Clear liquid stools before a colon resection are expected and indicate proper bowel preparation, not an urgent concern.

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A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E","F","H","I"]

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Correct Answer is A

Explanation

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