A client in the preoperative staging area is scheduled for an elective surgical procedure and has previously signed the informed consent document. When the practical nurse (PN) approaches to administer a prescribed preoperative sedative, the client abruptly declares, 'I have changed my mind. I am refusing this surgery.' Arrange the following nursing actions in the correct priority order from first to last.
- 1Withhold the administration of the prescribed preoperative sedative medication.
- 2Ask open-ended questions to explore the client's reasons for withdrawing their consent.
- 3Notify the attending surgeon and the supervising registered nurse (RN) of the client's decision.
- 4Document the client's exact verbal statement and the subsequent notifications in the medical record.
Answer
The correct sequence prioritizes client safety and legal capacity by first withholding the sedative, followed by exploring the client's concerns, notifying the provider and RN, and finally documenting the event.
The sequence follows the nursing process and clinical prioritization principles: safety first (holding the medication to preserve cognitive capacity), followed by data collection (assessing reasons), implementation and communication (notifying the provider), and finally, documentation.
Step-by-Step Solution
Key Concept
When a client revokes informed consent, the nurse must prioritize maintaining the client's cognitive capacity by withholding mind-altering medications, followed by data collection and immediate communication to the provider responsible for the procedure.
Estimated Time:1m 30s