A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?
"It is time to sign the consent so your treatment can begin."
"Have you discussed other treatments with your provider?"
"I can inform the surgeon you do not want the surgery."
"I would not have this type of surgery if I were you."
The Correct Answer is B
Rationale:
A. "It is time to sign the consent so your treatment can begin." dismisses the client's valid question about alternative options and does not address their concern.
B. "Have you discussed other treatments with your provider?" is an appropriate response as it encourages the client to seek information about alternatives from their healthcare provider, who can offer comprehensive options and explanations.
C. "I can inform the surgeon you do not want the surgery." does not address the client's question about alternatives and assumes the client’s decision without further discussion.
D. "I would not have this type of surgery if I were you." is a personal opinion and is not appropriate for a nurse to provide, as it is not based on the client’s individual medical needs or informed consent principles.
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Correct Answer is C
Explanation
Rationale:
A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.
B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.
C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.
D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.
Correct Answer is B
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.