A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
Postpone the procedure until the staff contacts the guardian.
Obtain consent from the client.
Prepare the client for surgery with implied consent.
Request that the provider sign the consent form.
The Correct Answer is C
Rationale:
A. Postponing the procedure could put the client at risk if the appendicitis worsens.
B. Obtaining consent from the client may not be possible due to the client's developmental disability.
C. Preparing the client for surgery with implied consent is appropriate when the client is unable to provide consent and the procedure is urgent.
D. Requesting that the provider sign the consent form is not appropriate because the provider cannot provide consent on behalf of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,D,B,C,E
Explanation
A. Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B. Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C. Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.
E. Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
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