A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse’s signature on the form confirms which of the following requirements? (Select all that apply.)
The client speaks the same language as the nurse.
The client signed in the nurse’s presence.
The client was not coerced.
The client has legal authority to do so.
The client does not have a mental health condition.
Correct Answer : B,C,D
Choice A Reason:
The requirement that the client speaks the same language as the nurse is not a standard criterion for informed consent. While effective communication is crucial, the presence of an interpreter can facilitate understanding if there is a language barrier. The nurse’s signature does not confirm the language spoken by the client.
Choice B Reason:
The nurse’s signature on the informed consent form confirms that the client signed the document in the nurse’s presence. This is a standard practice to ensure that the consent was given voluntarily and that the client was present at the time of signing. It helps in verifying the authenticity of the consent.
Choice C Reason:
The nurse’s signature also confirms that the client was not coerced into signing the consent form. Informed consent must be given voluntarily, without any form of pressure or coercion. This ensures that the client’s decision is made freely and with full understanding of the procedure or treatment.
Choice D Reason:
The nurse’s signature confirms that the client has the legal authority to give consent. This means that the client is of legal age and has the mental capacity to understand the information provided and make an informed decision. It is essential to ensure that the client is legally competent to consent to the treatment or procedure.
Choice E Reason:
The requirement that the client does not have a mental health condition is not a standard criterion for informed consent. Clients with mental health conditions can still provide informed consent if they have the capacity to understand the information and make a decision. The nurse’s signature does not confirm the mental health status of the client.
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Correct Answer is D
Explanation
Choice A Reason:
Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.
Choice B Reason:
Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.
Choice C Reason:
Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.
Choice D Reason:
Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.
Correct Answer is B
Explanation
Choice A Reason:
While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression.
Choice B Reason:
A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient’s airway is maintained and to prevent respiratory arrest.
Choice C Reason:
Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient’s respiratory function takes precedence.
Choice D Reason:
A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.