NCLEX RN Questions & Answers with Rationale

A client in labor is being prepared for a cesarean birth. The most important nursing intervention before the anesthesia is administered would be to:

1. Prepare the abdomen

2. Obtain an informed consent

3. Initiate an intravenous infusion

4. Insert an indwelling urinary catheter

Answer & Rationale

2. is the Answer - Obtaining informed consent is the priority before anesthesia is administered

All the other options can be done later or it is not the priority.

A female client is scheduled for a hysterectomy. When discussing the preoperative preparation, the nurse identifies that the client has no understanding of the surgery. The nurse should:

a) Describe the proposed surgery to the client

b) Proceed with implementing the preoperative plan

c) Notify the physician that the client needs information

d) Explain to the client gently that she should have asked more questions

Answer and Rationales

c) Legally, the person performing the surgery is responsible to inform the client adequately; the nurse may clarify information, witness the client's signature and cosign the consent form.

a) beyond the scope of nursing practice

b) nurse could face criminal charges of assault and battery because of lack of informed consent

d) blames the client.  Responsibility of the physician to impart the information and the nurse's role to clarify information and witness the client's written informed consent.