A nurse is obtaining informed consent for an adolescent who is scheduled for a cardiac catheterization. The adolescent’s guardian states, “I don’t understand why they need to do this procedure.”. Which of the following actions should the nurse take?
Explain the procedure to the adolescent and their guardian.
Witness the adolescent’s signature on the informed consent form.
Request assistance from the anesthesiologist to clarify the misunderstanding.
Notify the provider who is scheduled to perform the procedure.
The Correct Answer is D
Choice A rationale
While explaining the procedure to the adolescent and their guardian is important, it is not the nurse’s primary responsibility to provide detailed explanations of the procedure. This should be done by the provider performing the procedure.
Choice B rationale
Witnessing the adolescent’s signature on the informed consent form is part of the nurse’s role, but it does not address the guardian’s lack of understanding about the procedure.
Choice C rationale
Requesting assistance from the anesthesiologist to clarify the misunderstanding is not appropriate, as the anesthesiologist may not be the best person to explain the procedure. The provider performing the procedure should be the one to provide clarification.
Choice D rationale
Notifying the provider who is scheduled to perform the procedure is the correct action. The provider is responsible for ensuring that the patient and their guardian fully understand the procedure and its risks and benefits before obtaining informed consent.
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Correct Answer is B
Explanation
Choice A rationale
Increased throat pain is common after a tonsillectomy and can be managed with pain relief measures. It is not the most critical finding.
Choice B rationale
Frequent swallowing can indicate bleeding at the surgical site, which is a serious complication that requires immediate attention.
Choice C rationale
Refusal to drink clear liquids is concerning for dehydration but is not as immediately critical as signs of bleeding.
Choice D rationale
Crying often can be due to pain or discomfort but is not as critical as signs of bleeding.
Correct Answer is B
Explanation
Choice A rationale
Assisting the adolescent to ambulate 12 hours following surgery is not recommended. Early ambulation is important, but 12 hours post-surgery is too soon and can lead to complications such as increased pain and risk of injury.
Choice B rationale
Ensuring two nurses logroll the adolescent every 2 hours is crucial. Logrolling helps maintain spinal alignment and prevents complications such as pressure ulcers and respiratory issues.
Choice C rationale
Maintaining the head of the bed at a 30° angle is not appropriate immediately post-surgery as it can increase pressure on the surgical site and compromise spinal alignment.
Choice D rationale
Offering sips of water 4 hours following surgery is not recommended. Postoperative patients are usually kept NPO (nothing by mouth) for a certain period to prevent aspiration and other complications.