A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Irrigation of a wound with antibiotic solution

Insertion of a nasogastric tube

Placement of a central venous catheter

Administration of an iron injection using Z-track technique

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B.   Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C.   Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D.   Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.

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Correct Answer is A

Explanation

A. Correct. Furosemide is a loop diuretic that helps eliminate excess fluid and sodium from the body by increasing urine production. Increased urinary output is an indication that the medication is effectively managing fluid overload, a common issue in heart failure.

B. Incorrect. While a decreased BUN (blood urea nitrogen. level might occur due to improved kidney function, it is not a direct indicator of furosemide's effectiveness.

C. Incorrect. An increased weight suggests fluid retention, which would not indicate the effectiveness of furosemide.

D. Incorrect. Decreased hemoglobin levels may be due to various factors and are not directly related to the effectiveness of furosemide.

A. Apply the restraint under the client's clothes. B. Place the client in a sitting position. C. Tie the restraint to the railing of the client's bed. D. Ensure the restraint is placed across the client's chest.

Correct Answer is B

Explanation

A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.

B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.

C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.

D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.

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A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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