A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Removal of staples from a surgical wound.

Providing a sputum specimen.

Receiving moderate sedation.

Collection of a blood specimen for ABGS.

Answer and Explanation

The Correct Answer is C

Answer is c. Receiving moderate sedation.

a. Removal of staples from a surgical wound: This procedure is typically considered routine and minimally invasive, involving the removal of staples used for wound closure. While it involves physical manipulation of the wound site, it does not carry significant risks or require the alteration of the patient's consciousness. Therefore, obtaining informed consent for this procedure is not typically necessary as it falls within the standard of care for post-operative wound management.

b. Providing a sputum specimen: Collecting a sputum specimen is a non-invasive procedure commonly performed to aid in the diagnosis of respiratory conditions such as infections or chronic lung diseases. It involves expectorating mucus from the respiratory tract, which does not pose significant risks to the patient. As such, informed consent is usually not required for this procedure since it is relatively simple and does not involve any invasive interventions or alteration of consciousness.

c. Receiving moderate sedation: Correct. Moderate sedation involves the administration of drugs, typically benzodiazepines or opioids, to induce a state of decreased consciousness and relaxation while maintaining the patient's ability to respond to verbal commands and physical stimulation. This procedure carries inherent risks, including respiratory depression, cardiovascular complications, and potential allergic reactions to the medications used. Due to the potential for adverse effects and the altered state of consciousness induced by moderate sedation, informed consent is necessary to ensure that patients understand the risks and benefits of the procedure before it is performed.

d. Collection of a blood specimen for ABGs: Arterial blood gas (ABG) analysis involves the collection of a blood sample from an artery, typically the radial artery in the wrist, to assess the patient's acid-base balance, oxygenation status, and ventilation. While this procedure does involve puncturing the skin and accessing the arterial blood supply, it is considered a standard diagnostic test in many clinical settings. However, the invasiveness of the procedure and potential risks such as bleeding, hematoma formation, and arterial injury may necessitate informed consent in certain situations, especially if the patient has underlying coagulopathies or other risk factors that could increase the likelihood of complications.

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Correct Answer is A

Explanation

The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.

Choice A rationale:

The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.

Choice B rationale:

Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.

Choice C rationale:

The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.

Choice D rationale:

The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.

A. Show the AP how to remove an indwelling urinary catheter. B. Review the AP's skill competency checklist. C. Ask the AP if they know how to remove an indwelling urinary catheter. D. Pair the newly hired AP with an experienced AP.

Correct Answer is B

Explanation

Choice A rationale:

Showing the AP how to remove an indwelling urinary catheter may not provide sufficient evidence of their competency to perform the task safely and effectively. This approach assumes that observation alone is enough to determine competence, which is not necessarily the case. It's important to have a more structured assessment of the AP's skills.

Choice B rationale:

Reviewing the AP's skill competency checklist is the most appropriate action to ensure the AP is qualified to remove the indwelling urinary catheter. Competency checklists outline specific skills and steps required for a task, and they serve as a standardized way to assess the AP's capabilities. This process ensures that the AP has received proper training and has demonstrated competence before performing the procedure independently.

Choice C rationale:

Simply asking the AP if they know how to remove an indwelling urinary catheter is not a comprehensive method for verifying their qualifications. Self-assessment can be unreliable and may not accurately reflect the AP's actual skill level. Relying solely on self-reporting could compromise patient safety and quality of care.

Choice D rationale:

Pairing the newly hired AP with an experienced AP might provide some guidance, but it doesn't systematically assess the individual's competence. The level of experience of the experienced AP may vary, and their ability to teach or evaluate the new AP's skills may not be standardized.

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A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?

Correct Answer is A

Explanation

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Correct Answer is B

Explanation

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