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
Increasing the dwell time during the next dialysis infusion is not appropriate. The issue is with the outflow, not the dwell time. Increasing the dwell time could exacerbate the problem.
Choice B rationale
Instructing the child to change position is correct. Changing position can help facilitate the drainage of dialysate by allowing gravity to assist in the outflow process.
Choice C rationale
Increasing oral fluid intake is not relevant to the issue of minimal dialysate outflow. The problem lies with the mechanical process of dialysis, not fluid intake.
Choice D rationale
Assessing for a bruit at the site of the peritoneal catheter is not directly related to resolving minimal dialysate outflow. A bruit indicates blood flow through a vascular access, not the peritoneal catheter.
Correct Answer is D
Explanation
Choice A rationale
Rotavirus vaccination is typically administered in infancy, not at 5 years of age. The rotavirus vaccine is given to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration in young children. By the age of 5, children have usually completed the rotavirus vaccination series.
Choice B rationale
Hepatitis B vaccination is also typically completed in infancy. The hepatitis B vaccine is given to infants to protect against hepatitis B virus infection, which can cause chronic liver disease and liver cancer. By the age of 5, children who are up-to-date with their immunizations have usually completed the hepatitis B vaccination series.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccination is typically completed by 15 months of age. The Hib vaccine protects against infections caused by Haemophilus influenzae type b, such as meningitis, pneumonia, and epiglottitis. By the age of 5, children who are up-to-date with their immunizations have usually completed the Hib vaccination series.
Choice D rationale
The second dose of the varicella vaccine is usually given at 4-6 years of age. The varicella vaccine protects against chickenpox, a highly contagious viral infection that causes an itchy rash and fever. Administering the second dose of the varicella vaccine at this age helps ensure that the child has adequate immunity against chickenpox.