A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

A client who has hearing loss with a friend interpreting

A client who has not spoken with the provider yet

A 15-year-old client whose caregiver is not at the bedside.

A married 16-year-old client accompanied by their spouse

Answer and Explanation

The Correct Answer is D

A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.

B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.

C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.

D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.

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Correct Answer is C

Explanation

A. "I do not need to sign a consent form before this procedure.": A signed informed consent form is required before an intravenous pyelogram (IVP) because it involves the injection of contrast dye, which carries risks such as allergic reactions and kidney injury.

B. "I should limit my fluid intake for 2 days after the procedure.": Clients are encouraged to increase fluid intake after an IVP to help flush the contrast dye from their system and reduce the risk of kidney complications, not limit fluids.

C. "I will feel a warming sensation after the injection of the dye.": This statement shows understanding. It is common to feel a warm, flushing sensation or a metallic taste in the mouth shortly after the contrast dye is injected during an IVP. These effects are usually brief and harmless.

D. "I can have a meal up to 2 hours before the procedure.": Clients are typically instructed to be NPO (nothing by mouth) for a certain period, often after midnight, before the procedure to reduce the risk of aspiration and to ensure clear imaging. Eating close to the procedure time is not recommended.

A. Place the client in a supine position B. Empty the collection chamber every 8 hr C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4hr

Correct Answer is C

Explanation

A. Place the client in a supine position: A supine position can impair lung expansion and increase the risk of respiratory complications. Clients with a chest tube are best positioned in a semi-Fowler’s or high-Fowler’s position to promote lung re-expansion and ease of breathing.

B. Empty the collection chamber every 8 hr: The collection chamber in a chest drainage system should not be emptied routinely, it should be emptied as needed to prevent it from overfilling. It is a closed system, and breaking it by emptying can introduce infection or disrupt the pressure needed for effective drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the chest drainage system below chest level uses gravity to promote drainage and prevents backflow of fluid or air into the pleural space. This positioning is essential to maintain the effectiveness and safety of the chest tube system.

D. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended as it can lead to a dangerous buildup of air (tension pneumothorax). Clamping is reserved for specific, short-term procedures under direct provider orders, such as changing the drainage system.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

Nursing Test Bank

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Correct Answer is C

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