A 38-year-old client who is a Jehovah's Witness is involved in a major motor vehicle accident. The client was brought to the emergency department and was found to have lost too much blood, thus requiring a blood transfusion. The client is able to respond to questions appropriately. Which action should the nurse take in this situation?

Only fresh frozen plasma should be transfused to the client.

An immediate blood transfusion should be started due to the client's condition.

The client should be asked to decide about the blood transfusion.

The client's family should be notified immediately of the situation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

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Correct Answer is D

Explanation

Choice A rationale:

Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.

Choice B rationale:

Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.

Choice C rationale:

Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.

Choice D rationale:

Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.

A. Restrict the client's fluid intake to less than 2 L/day. B. Instruct the client to use pursed-lip breathing. C. Have the client use the early-morning hours for exercise and activity. D. Provide the client with a low-protein diet.

Correct Answer is B

Explanation

Choice A rationale:

Restricting the client's fluid intake to less than 2 L/day is not an appropriate intervention for a client with COPD. Adequate hydration is important to help thin mucus secretions and improve respiratory function. Restricting fluids can lead to thicker mucus and exacerbate breathing difficulties.

Choice B rationale:

Instructing the client to use pursed-lip breathing is a beneficial intervention for someone with COPD. Pursed-lip breathing helps improve breathing efficiency by promoting better air exchange and preventing air trapping, which is common in COPD. It helps slow down breathing and increases oxygen saturation.

Choice C rationale:

Having the client use the early-morning hours for exercise and activity might not be the best choice. Morning hours can be when clients with COPD experience more respiratory symptoms. It's advisable to schedule activities during times when the client feels more comfortable and less breathless.

Choice D rationale:

Providing the client with a low-protein diet is not a relevant intervention for COPD management. COPD primarily affects the lungs and respiratory system, and a low-protein diet is not a standard part of its management. Nutritional recommendations for COPD typically focus on maintaining a balanced diet to support overall health.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is B

Explanation

A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

A Medical-Surgical nurse is preparing to administer Furosemide to a patient who is having severe heart failure. Which route of administration should the nurse use to provide the fastest and most complete absorption of Furosemide?

A Medical-Surgical nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?

A patient has difficulty in breathing. The nurse provides oxygen therapy to the patient, after which the patient feels better. Which principle is involved in this situation?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).