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
Administration of an iron injection using Z-track technique
Placement of a central venous catheter
Insertion of a nasogastric tube
The Correct Answer is C
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.

Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct answer: B
A. Place no more than one small pillow in the crib
The American Academy of Pediatrics (AAP) recommends that infants should sleep on a firm and flat surface without any pillows, blankets, or soft bedding. These items can pose a suffocation risk.So, the nurse should advise against using any pillows in the crib.
B. This is agood recommendation. Bibs can be a choking hazard during sleep.Removing them ensures the baby’s safety and reduces the risk of accidental suffocation
C. Making sure the crib mattress is soft in (option C) is not recommended. The crib mattress should be firm to provide a safe sleeping surface for the infant. Soft mattresses can increase the risk of suffocation.
D. Starting to use a highchair for feedings at 3 months old in (option D) is not typically necessary or developmentally appropriate. At this age, infants are typically fed while being held in a caregiver's arms or in a reclined position, such as in a baby bouncer or supported seat.
Correct Answer is B
Explanation
The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.

Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.
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