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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.
B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.
C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.
D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.
Correct Answer is B
Explanation
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
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