A client with end-stage renal disease is in the preoperative unit awaiting an elective arteriovenous (AV) fistula creation. The surgeon obtained informed consent the previous evening. As the nurse prepares to administer the ordered on-call intravenous midazolam, the client tearfully states, 'I changed my mind. I am too scared to have this surgery today.' In what order should the nurse perform the following actions? Arrange the actions from first to last.
- 1Withhold the intravenous midazolam.
- 2Ask the client to share their specific fears regarding the surgery.
- 3Reassure the client that they have the right to withdraw their consent.
- 4Contact the surgeon to report the client's revocation of consent.
- 5Document the client's statement, the withheld medication, and the surgeon notification.
Answer
The correct sequence is: 1) Withhold the intravenous midazolam, 2) Ask the client to share their specific fears, 3) Reassure the client that they have the right to withdraw consent, 4) Contact the surgeon, 5) Document the events.
The nurse's immediate priority is to prevent the administration of any medication that alters cognitive function, ensuring the client maintains the legal capacity to revoke consent. Next, the nurse applies the nursing process by assessing the client's specific concerns. As an advocate, the nurse then validates the client's right to refuse treatment. Once the situation is fully assessed and the client's rights are reinforced, the nurse communicates the change in status to the surgeon, who is responsible for the procedure. Finally, the nurse documents all assessments, interventions, and communications in the medical record to maintain legal compliance.
Step-by-Step Solution
Key Concept
Informed Consent Revocation and Patient Advocacy