A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
Obtain the client's consent.
Explain the procedure to the client if they do not understand.
Witness the client's signature.
Explain the risks and benefits of the procedure.
The Correct Answer is C
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.
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Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
Correct Answer is D
Explanation
A. Shaving the hair off the skin where the electrodes will be placed is correct, as it helps ensure proper contact and effectiveness of the TENS therapy.
B. Expressing hope to reduce the need for pain pills indicates the client understands the potential benefit of TENS in managing pain.
C. Wishing to avoid attaching electrodes indicates a common apprehension about the treatment but does not necessarily signify a misunderstanding of the TENS process.
D. The statement about having to be in the hospital suggests a misunderstanding since TENS is often used as an outpatient therapy and does not typically require hospitalization. This indicates the client needs further education about the treatment setting and process.