A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?

Obtain consent from the client.

Acknowledge the client and sign the consent.

Obtain consent from a relative of the client.

Delay the procedure.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.

Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.

Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.

Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.

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Correct Answer is ["C","D","F"]

Explanation

Situations that can lead to a tort against a nurse include repeating a rumor about a patient's personal life in a staﬀ meeting, telling friends something unusual about a patient that was noted in the patient's chart, and forcing a patient to take medication against their will. These actions can result in legal action against the nurse for invasion of privacy or battery.

Option A is incorrect because referring a stranger to the patient or their family for details regarding the patient is an appropriate action.

Option Bis incorrect because respecting a patient's right to refuse treatment on religious grounds is an appropriate action.

Option Eis incorrect because placing an alarm on the bed of a patient prone to falling is an appropriate action to ensure their safety.

A. "I will notify the charge nurse of your request to have only male staﬀ members assigned to care for you." B. "I can arrange for a male AP to do your personal hygiene care." C. "The AP assigned to care for you is very capable and has taken care of other men." D. "Why don't you want a female AP assigned to your care?"

Correct Answer is A

Explanation

The nurse should give the statement "I will notify the charge nurse of your request to have only male staﬀ members assigned to care for you." This response shows that the nurse is respecting the client's wishes and taking appropriate action to address their concerns.
Option B is incorrect because it is not within the nurse's scope of practice to arrange for a specific AP to provide care.
Option C is incorrect because it does not address the client's concerns or wishes.
Option D is incorrect because it may be perceived as confrontational and does not address the client's concerns in a respectful and professional manner.

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A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which situation can lead to a tort against a nurse? SELECT ALL THAT APPLY:

Correct Answer is ["C","D","F"]

Explanation

A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

Correct Answer is A

Explanation

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