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
Semi-Fowler’s position is not suitable for a lumbar puncture as it does not provide the necessary spinal flexion.
Choice B rationale
The lateral position is ideal for a lumbar puncture as it allows for proper spinal alignment and access to the lumbar region.
Choice C rationale
Supine position is not appropriate for a lumbar puncture as it does not provide the necessary spinal flexion.
Choice D rationale
Prone position is not suitable for a lumbar puncture as it does not allow for proper access to the lumbar region.
Correct Answer is B
Explanation
Choice A rationale
Serous chest tube drainage is a normal finding and does not typically indicate a complication. It is usually clear or pale yellow fluid that is expected after surgery.
Choice B rationale
Chest tube drainage of 200 mL in 1 hour is excessive and should be reported to the provider. This could indicate active bleeding or other complications that require immediate attention.
Choice C rationale
Fluctuation in the water-sealed chamber, also known as tidaling, is a normal finding and indicates that the chest tube is functioning properly. It reflects changes in pressure within the pleural space during respiration.
Choice D rationale
A respiratory rate of 22/min is within the normal range for a school-age child and does not typically indicate a complication.