A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

Remind the client that a signed informed consent form is a legally binding document.

Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

Proceed with preparation of the patient for the surgical procedure.

Inform the surgical team to cancel the client’s surgery.

Answer and Explanation

The Correct Answer is B

Choice A reason: Reminding the client that a signed informed consent form is a legally binding document is incorrect. Informed consent is based on the principle of patient autonomy, meaning the patient has the right to withdraw consent at any time. The nurse should respect the client’s decision and not pressure them into proceeding with the procedure.

Choice B reason: Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is the appropriate action. The surgeon needs to be informed immediately so that they can discuss the client’s concerns, provide additional information if needed, and respect the client’s decision. This ensures that the client’s autonomy and rights are upheld.

Choice C reason: Proceeding with preparation of the patient for the surgical procedure is not appropriate once the client has withdrawn consent. Continuing with the preparation would violate the client’s rights and could lead to legal and ethical issues. The nurse must halt any further preparation and inform the relevant medical staff of the client’s decision.

Choice D reason: Informing the surgical team to cancel the client’s surgery is a step that may be taken after discussing the withdrawal of consent with the surgeon. The nurse should first notify the surgeon, who will then make the decision to cancel the surgery based on the client’s wishes. Directly informing the surgical team without consulting the surgeon first is not the correct protocol.

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Correct Answer is A

Explanation

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

A. Wash the area of the puncture thoroughly with soap and water. B. Notify employee health services. C. Complete an incident report. D. Report the incident to the charge nurse.

Correct Answer is A

Explanation

Choice A Reason:

Washing the area of the puncture thoroughly with soap and water is the first and most immediate action the nurse should take. This step helps to reduce the risk of infection by removing any potential contaminants from the puncture site. It is a crucial initial response to any needlestick injury to minimize the risk of bloodborne pathogen transmission. Proper hand hygiene is essential in preventing infections and ensuring the safety of healthcare workers.

Choice B Reason:

Notifying employee health services is an important step that should follow the initial first aid. Employee health services will provide further evaluation, testing, and follow-up care as needed. They will also guide the nurse on any necessary post-exposure prophylaxis and additional steps to take. However, this is not the first action to take immediately after the injury.

Choice C Reason:

Completing an incident report is a necessary step to document the needlestick injury. This report helps in tracking and preventing future incidents, ensuring that proper protocols are followed, and providing data for workplace safety improvements. While important, this step should be taken after the initial first aid and notification of employee health services.

Choice D Reason:

Reporting the incident to the charge nurse is also an important step in the process. The charge nurse needs to be informed about the incident to ensure that appropriate follow-up actions are taken and to provide support to the affected nurse. However, this step should come after the immediate first aid and notification of employee health services.

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A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

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