An emergency department nurse is admitting a 16-year-old client who has acute abdominal pain and is accompanied by his grandmother. The client requires an emergency appendectomy. Which of the following statements should the nurse make to the grandmother?

"If his parents agree by phone that you may give consent, we'll need you to sign the form."

"Because he is 16 and this is an emergency, he has to sign the consent form."

"We cannot take him to the surgical suite until one of his parents signs the consent form."

"The doctor will provide consent because his parents are not with him."

Answer and Explanation

The Correct Answer is A

A. "If his parents agree by phone that you may give consent, we'll need you to sign the form.": In emergency situations, verbal parental consent over the phone can be legally acceptable. If the parent delegates authority to the grandparent, written or verbal permission can authorize the grandparent to sign the consent.

B. "Because he is 16 and this is an emergency, he has to sign the consent form.": Most 16-year-olds are still considered minors and cannot independently provide legal consent for surgery unless they are emancipated or the procedure falls under minor-consent laws, which don’t include appendectomy.

C. "We cannot take him to the surgical suite until one of his parents signs the consent form.": In true emergencies, surgery can proceed without parental consent if delaying care would pose serious harm. While obtaining consent is ideal, it’s not always legally required in life-threatening situations.

D. "The doctor will provide consent because his parents are not with him.": Healthcare providers do not give legal consent for procedures. In emergencies, treatment can proceed without consent under implied consent laws, but the provider does not "sign" on the patient’s behalf.

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Correct Answer is D

Explanation

A. Measure the client’s rectal temperature daily:Rectal temperature measurement is contraindicated in immunosuppressed clients due to the risk of mucosal injury, which can introduce bacteria into the bloodstream and lead to sepsis.

B. Encourage ambulation in the facility’s hallways:While ambulation is beneficial for overall health, hallway ambulation exposes immunosuppressed clients to environmental pathogens and increases their infection risk. Exercise should be encouraged in a protected and sanitized space.

C. Monitor the client’s temperature every 8 hr:More frequent temperature monitoring is required in clients undergoing chemotherapy with immunosuppression, as even a slight elevation may signal an early infection. Monitoring every 8 hours may not be adequate.

D. Monitor the client’s WBC count daily:Daily monitoring of white blood cell count is essential to detect neutropenia early. A low WBC count increases the risk for infection, and frequent monitoring allows for timely interventions like protective isolation or treatment.

A. Insert an NG tube for a client who requires enteral feedings. B. Transfer a client to physical therapy. C. Obtain a client's vital signs every 4 hr. D. Instruct a client on the use of an incentive spirometer. E. Record a client's intake after each meal.

Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings: Inserting an NG tube requires nursing knowledge, assessment skills, and sterile technique. This is beyond the scope of practice for assistive personnel and must be performed by a licensed nurse.

B. Transfer a client to physical therapy: Transferring stable clients is within the role of assistive personnel, especially when proper transfer techniques are used and the client does not require complex assessments during the transfer.

C. Obtain a client's vital signs every 4 hr: Monitoring and recording routine vital signs is a standard task for assistive personnel. The nurse retains responsibility for interpreting the findings and acting on abnormal values.

D. Instruct a client on the use of an incentive spirometer: Teaching or reinforcing client education requires nursing judgment and is not within the scope of practice for assistive personnel. This task should be performed by a licensed nurse.

E. Record a client's intake after each meal: Documenting intake, including the amount consumed, is appropriate for assistive personnel. The nurse will then interpret this data as part of the client’s fluid or nutritional status monitoring.

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An emergency department nurse is admitting a 16-year-old client who has acute abdominal pain and is accompanied by his grandmother. The client requires an emergency appendectomy. Which of the following statements should the nurse make to the grandmother?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has chemotherapy-related immunosuppression. Which of the following interventions should the nurse add to the client's plan of care?

Correct Answer is D

Explanation

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Correct Answer is ["B","C","E"]

Explanation

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