A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
Reassuring the partner of a client who sustained a closed head injury
Reinforcing a client's dressing for the surgical site of an above-the-knee amputation
Taking a telephone prescription about a client who is to be transferred from PACU
Assessing a client who experiences unilateral calf pain when ambulating
The Correct Answer is D
Rationale:
A. Reassuring the partner is important for emotional support but does not directly impact the immediate safety of clients.
B. Reinforcing a dressing is important for wound care but does not address urgent concerns.
C. Taking a telephone prescription is necessary but not as immediate as addressing a potential complication.
D. Assessing a client with unilateral calf pain is the priority as it may indicate a serious condition such as deep vein thrombosis (DVT), which requires immediate evaluation and intervention.
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Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Verify the client understands the surgical procedure ensures the client is making an informed decision based on a clear understanding of the procedure, risks, and benefits.
B. Validate the signature is authentic is crucial to confirm that the consent form is genuinely signed by the client, indicating their agreement to proceed
.
C. Confirm that the consent is voluntary ensures that the client is not coerced into giving consent, upholding the principle of autonomy.
D. Explain the surgical procedure to the client is the responsibility of the surgeon or the provider, not the nurse. The nurse’s role is to witness the consent process and ensure that the client has been provided with and understands the information.
E. Establishing that the client is able to pay is not related to the informed consent process. Financial aspects are handled separately from the consent for treatment.
Correct Answer is D
Explanation
Rationale:
A. HICS focuses on organizing and managing internal facility operations rather than mobilizing external multidisciplinary responders.
B. HICS does not directly ensure the availability of specific medical supplies; this is usually managed through other systems or protocols.
C. HICS is primarily concerned with internal facility management, not providing additional responders from outside agencies.
D. HICS helps to define roles, responsibilities, and reporting channels within the facility during a disaster, ensuring effective internal management.