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 D
Explanation
Choice A rationale
Disposable diapers are not typically sources of healthcare-associated infections if used appropriately. They are designed for single use and are disposed of after use, minimizing the risk of infection.
Choice B rationale
Protective plastic gowns are not typically sources of healthcare-associated infections if used appropriately. They are designed to protect healthcare workers and patients from the spread of infections and are disposed of after use.
Choice C rationale
Unopened bottles of formula are not typically sources of healthcare-associated infections. They are sealed and sterile until opened, reducing the risk of contamination.
Choice D rationale
Bedside computer keyboards can harbor pathogens and serve as fomites for transmitting infections. They are frequently touched by healthcare workers and can become contaminated with pathogens, making them a common source of healthcare-associated infections.
Correct Answer is D
Explanation
Choice A rationale
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.8 to 2 ng/mL) for toddlers receiving digoxin therapy. This level does not require a revision of the plan of care.
Choice B rationale
An apical pulse of 100/min is within the normal range for toddlers. Digoxin therapy requires monitoring of the heart rate, but this pulse rate does not necessitate a change in the plan of care.
Choice C rationale
A potassium level of 4.0 mEq/L is within the normal range (3.4 to 4.7 mEq/L) for toddlers. This electrolyte level does not require a revision of the plan of care.
Choice D rationale
Vomiting is a potential sign of digoxin toxicity. A toddler who has vomited 2 times in the last hour may be experiencing digoxin toxicity, and the plan of care should be revised to address this issue.