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 B
Explanation
Choice A Reason:
Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process.
Choice B Reason:
Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client’s pain during the procedure, ensuring comfort and compliance.
Choice C Reason:
Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique.
Choice D Reason:
Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.
Correct Answer is A
Explanation
Choice A Reason:
Tuberculosis (TB) is a highly contagious bacterial infection that primarily affects the lungs and is spread through airborne particles. When a person with active TB coughs, sneezes, or talks, they release tiny droplets containing the bacteria into the air, which can be inhaled by others1. Therefore, placing a client with TB in airborne precautions is essential to prevent the spread of the infection. This involves using a negative pressure room and requiring healthcare workers to wear N95 respirators or higher-level protection.
Choice B Reason:
Pneumonia is an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus. While pneumonia can be caused by bacteria, viruses, or fungi, it is typically spread through respiratory droplets rather than airborne particles. Therefore, droplet precautions, rather than airborne precautions, are usually sufficient for managing clients with pneumonia. This includes wearing masks and maintaining a safe distance from the infected person.
Choice C Reason:
Shigella is a bacterial infection that primarily affects the intestines and is spread through the fecal-oral route. It is not transmitted through the air, so airborne precautions are not necessary. Instead, contact precautions are recommended to prevent the spread of Shigella, which involves wearing gloves and gowns when handling the patient or their environment and practicing good hand hygiene.
Choice D Reason:
Strep throat is a bacterial infection caused by group A Streptococcus. It is spread through respiratory droplets when an infected person coughs or sneezes. Similar to pneumonia, droplet precautions are sufficient for managing clients with strep throat. This includes wearing masks and maintaining a safe distance from the infected person to prevent the spread of the bacteria.