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?

Notify risk management before initiating treatment.

Proceed with treatment without obtaining written consent.

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

Have the client sign a consent for treatment.

Answer and Explanation

The Correct Answer is B

A.   Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B.   In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C.   Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D.   Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.

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Correct Answer is D

Explanation

A. Reviewing facility policies is important but might not immediately address the reasons why the nurses are not taking breaks.
B. Discussing time management strategies might be helpful, but it's crucial to first understand the reasons behind the nurses' behavior.
C. Providing coverage for the nurses' breaks might be a short-term solution but doesn't address the underlying reasons for not taking breaks.
D. Determining the reasons the nurses are not taking scheduled breaks is the initial step to understand if it's due to workload, personal choice, or other factors. This information can guide appropriate interventions or support for the nurses.

A. Keep the four side rails up on beds at night. B. Institute rounds every 2 hr during the day to offer toileting C. Accompany residents older than 85 years of age during ambulation D. Apply vest restraints on residents who are confused. E. Apply vest restraints on residents who are confused.

Correct Answer is B

Explanation

A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.

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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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