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. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.
Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.