A nurse is caring for a client who is scheduled for a tubal ligation. The client expresses uncertainty about having the procedure. Which of the following responses should the nurse make?
"We can still cancel the procedure if you decide that's what you want."
"Are you worried that the procedure will affect your libido?"
"You have already signed the informed consent form."
"You should discuss this with your partner before making a final decision."
The Correct Answer is A
A. "We can still cancel the procedure if you decide that's what you want.":
This is a therapeutic response that respects the client’s autonomy and acknowledges that consent can be withdrawn at any time before the procedure begins.
B. "Are you worried that the procedure will affect your libido?":
This is a closed-ended and leading question that assumes the client’s reason without first exploring their concerns.
C. "You have already signed the informed consent form.":
This is dismissive and ignores the client’s present concerns; signing a consent form does not remove the client’s right to change their mind.
D. "You should discuss this with your partner before making a final decision.":
While involving a partner may be helpful, the decision ultimately belongs to the client, and this statement could imply the nurse is shifting responsibility away from the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Client 1:
Cefaclor was scheduled for 0800 and given at 0830 - this is a 30-minute delay, which is generally acceptable unless the medication is time-critical (e.g., insulin, antibiotics for sepsis). Since antibiotics should be given on time, but a 30-min delay is within the acceptable window, this does not require an incident report.
B. Client 2:
The client vomited undigested food and medication 30 minutes after administration. This is a medication effectiveness concern that should be documented and reported because the dose may need to be repeated, and the provider must be notified. An incident report is appropriate.
C. Client 4:
Furosemide was prescribed PO but administered IV at 1400. This is a route error, which is a medication administration error requiring an incident report.
D. Client 3:
Warfarin was administered despite an INR of 3.8 (above the hold parameter of >3.5). This is a clear medication error with potential for harm, requiring an incident report.
E. Client 5:
Gentamicin dose was prescribed at 150 mg IM, but 300 mg IM was given - this is a double dose and a serious medication error requiring immediate incident reporting.
F. Client 6:
Atenolol was appropriately held only if apical pulse <60/min; pulse was 62/min, so administration was within parameters - no error here.
Correct Answer is C
Explanation
A. Abdominal CT scan with contrast:
This is a diagnostic procedure that typically requires separate informed consent due to the use of contrast dye and potential risks.
B. Administration of 1 unit of fresh frozen plasma:
Blood product administration requires informed consent due to associated risks such as transfusion reactions.
C. Insertion of an NG tube to low intermittent suction:
This is a standard nursing/medical procedure performed as part of routine care for gastrointestinal conditions and is generally covered under general admission consent.
D. Esophagogastroduodenoscopy:
This is an invasive endoscopic procedure that requires separate, specific informed consent.
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