A nurse is reviewing a client's medical record and notices that there is no documentation of informed consent for a surgical procedure that was performed earlier that day. Which action should the nurse take?
Report the incident to the risk management department.
Document the incident in the client's medical record.
Contact the health care provider who performed the procedure.
Notify the client's family members of the incident.
The Correct Answer is A
Rationale: The nurse should report the incident to the risk management department, as this is a serious breach of legal and ethical principles that could result in legal action or disciplinary measures. The risk management department is responsible for identifying, analyzing, and minimizing risks that could harm clients, staff, or the organization.
Incorrect options:
B) Document the incident in the client's medical record. - This is an incorrect action, as it does not address the issue or prevent further harm. The nurse should not document anything in the client's medical record that is not related to their care or treatment, as this could be used as evidence in a lawsuit or investigation.
C) Contact the health care provider who performed the procedure. - This is an incorrect action, as it does not address the issue or prevent further harm. The nurse should not confront or accuse the health care provider who performed the procedure, as this could create conflict or hostility. The nurse should report the incident to the appropriate authority, such as the risk management department or the nursing supervisor.
D) Notify the client's family members of the incident. - This is an incorrect action, as it does not address the issue or prevent further harm. The nurse should not disclose any information about the client's care or treatment to anyone who is not authorized to receive it, unless there is a legal obligation or a valid consent from the client.
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Related Questions
Correct Answer is A
Explanation
Rationale: The appropriate action by the nurse in this situation is to confirm the DNR order with
the client and document the conversation in the medical record. The nurse should ensure that
the client understands what a DNR order means and that they agree with it. The nurse should
also respect the client's right to change their mind at any time and revoke the DNR order if they wish.
Incorrect options:
B) Contact the physician and request that the DNR order be revoked, as the client has not given consent. - This is an inappropriate action, as it would violate the client's autonomy and dignity. The nurse should not assume that the client has not given consent, as they may have discussed their wishes with their health care proxy or physician beforehand. The nurse should confirm the DNR order with the client instead of requesting its revocation.
C) Respect the DNR order and provide palliative care to the client, as the health care proxy has authority to make decisions. - This is a partially correct action, as the nurse should respect the DNR order and provide palliative care to the client. However, the nurse should not rely solely on the health care proxy's authority to make decisions, asthe client is alert and oriented and may have their own preferences and opinions. The nurse should confirm the DNR order with the client as well.
Correct Answer is C
Explanation
Rationale: The nurse should empathize with the client's situation, but refuse to help them with their request to end their life by taking an overdose of medication. The nurse should explain that it is against their scope of practice and code of ethics to assist the client in ending their life, as this violates the principle of nonmaleficence, which states that nurses should do no harm or allow harm to occur.
Incorrect options:
A) "I understand that you are suffering, but I cannot help you with that. It is illegal and unethical for me to assist you in ending your life." - This is an incorrect response, as it does not show empathy or compassion for the client's situation. The nurse should not use legal or ethical terms that may sound harsh or judgmental to
the client.
B) "I respect your decision, but I cannot help you with that. It is against my personal and professional values to assist you in ending your life." - This is an incorrect response, as it does not show empathy or compassion for the client's situation. The nurse should not use personal or professional values that may sound biased or insensitive to
the client.
D) "I appreciate your honesty, but I cannot help you with that. It is against my moral and religious beliefs to assist you in ending your life." - This is an incorrect response, as it does not show empathy or compassion for the client's situation. The nurse should not use moral or religious beliefs that may sound intolerant or disrespectful to
the client.
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