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
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
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.