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 A
Explanation
Choice A rationale
A dietitian should be consulted for a newly admitted child to assess and plan for the child’s nutritional needs, especially if the child has specific dietary requirements or is at risk for malnutrition.
Choice B rationale
An occupational therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice C rationale
A physical therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice D rationale
A speech-language pathologist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Correct Answer is A
Explanation
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.