A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?
Administration of an enema.
Performance of a paracentesis.
Insertion of an indwelling urinary catheter.
Placement of an NG tube.
The Correct Answer is B
The correct answer is choice B: Performance of a paracentesis.
Choice A rationale:
Administration of an enema does not require informed consent in the same way that invasive procedures do. Enemas are typically considered routine nursing interventions and are not as invasive as the other options.
Choice B rationale:
This is the correct choice. A paracentesis is an invasive procedure that involves puncturing the abdominal cavity to withdraw fluid. Informed consent is required for procedures that carry potential risks, and paracentesis falls into this category due to the risk of complications such as infection, bleeding, or organ injury.
Choice C rationale:
Insertion of an indwelling urinary catheter is a common nursing procedure that, while invasive, does not typically require informed consent. However, the nurse should still explain the procedure to the client and obtain verbal consent, but it's not the same level of formal informed consent required for more invasive procedures.
Choice D rationale:
Placement of an NG tube, although uncomfortable, is not as invasive as a paracentesis. In most cases, NG tube placement is considered a medical or nursing intervention rather than a procedure that necessitates formal informed consent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
Correct Answer is D
Explanation
The correct answer is choice d. The client’s output was 60 mL for the past 3 hr.
Choice A rationale:
Voiding three times during the night (nocturia) is common in chronic kidney disease (CKD) due to the kidneys’ inability to concentrate urine. While it should be monitored, it is not the most urgent issue.
Choice B rationale:
Burning and discomfort with urination could indicate a urinary tract infection (UTI), which is important to address but not as immediately critical as low urine output.
Choice C rationale:
A WBC count of 11,000/mm² is slightly elevated and could indicate an infection or inflammation, but it is not as urgent as the low urine output.
Choice D rationale:
Low urine output (oliguria) of 60 mL over 3 hours is a critical finding in CKD patients. It indicates potential acute kidney injury or worsening kidney function, which requires immediate attention to prevent further complications.
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