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 B
Explanation
The correct answer is choice B. Client states, "I started to itch after taking that medication."
Choice A rationale:
"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.
Choice B rationale:
"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.
Choice C rationale:
"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.
Choice D rationale:
"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.
Correct Answer is D
Explanation
The correct answer is choice D: "Instruct the client to tilt their head forward while eating."
Choice A rationale:
Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.
Choice B rationale:
Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.
Choice C rationale:
Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.
Choice D rationale:
Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.
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