A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?
Provide information about alternate birth control methods.
Ask if the client has discussed the decision with their partner.
Emphasize the benefits of having the procedure.
Discuss the client's feelings about the procedure.
The Correct Answer is D
Choice A rationale: Providing information about other birth control methods is appropriate after the nurse explores the client's uncertainty, as it ensures the client's decision-making process is supported by understanding all available options.
Choice B rationale: While involving a partner can be helpful, the nurse’s primary responsibility is to the client’s autonomy; asking this first may shift the focus away from the client’s personal concerns.
Choice C rationale: Emphasizing only the benefits is non-therapeutic and biased. The nurse must remain neutral and allow the client to weigh both the benefits and risks of a permanent procedure.
Choice D rationale: Active listening and exploring the client's feelings are the first steps in the nursing process to address uncertainty. This allows the client to clarify their values and reach an informed decision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Reporting the findings to the hospital ethics committee is not the appropriate action in this scenario. Ventilator-associated pneumonia (VAP) is a clinical issue related to patient care and safety, not an ethical concern. The hospital ethics committee is generally responsible for addressing ethical dilemmas and conflicts.
Choice B rationale:
Alerting central supply is not the correct action in this situation. Central supply typically handles the procurement and distribution of medical supplies, equipment, and materials. While maintaining proper equipment and supplies is important, addressing VAP requires a focus on infection prevention and patient care practices.
Choice C rationale:
Filling out an incident report is not the best course of action for addressing an increase in ventilator-associated pneumonia. Incident reports are typically used to document unexpected events, accidents, or errors that occur in the healthcare setting. However, addressing the rise in VAP involves implementing measures to prevent and control infections, which falls under the purview of the quality improvement team.
Choice D rationale:
The correct action is to notify the quality improvement team. Ventilator-associated pneumonia is a healthcare-associated infection that can lead to serious complications for patients on ventilators. The quality improvement team is responsible for monitoring and improving the quality of patient care, including infection prevention and control. By notifying the quality improvement team, the nurse manager can initiate a comprehensive review of current practices, identify potential areas for improvement, and implement evidence-based interventions to reduce the incidence of VAP.
Correct Answer is C
Explanation
Choice A rationale:
Assigning clients who have had stem cell transplants to the same room is not a recommended practice. Clients with compromised immune systems should be isolated to reduce the risk of infection transmission. Placing them together increases the potential for exposure to infectious agents.
Choice B rationale:
Obtaining a rectal temperature on clients every 4 hours is not specifically related to caring for clients following stem cell transplants. Vital sign monitoring is essential, but the frequency and method of temperature measurement can vary based on the individual client's condition and clinical judgment.
Choice C rationale:
(Correct Choice) Wearing an N95 respirator mask while caring for clients following stem cell transplants is important due to their compromised immune systems. These clients are at higher risk of infections, and N95 masks provide enhanced respiratory protection against airborne pathogens.
Choice D rationale:
Placing clients in positive-pressure airflow rooms is not a standard practice for caring for clients following stem cell transplants. Positive-pressure rooms are often used for clients with conditions like immunodeficiency, but stem cell transplant recipients are generally placed in protective isolation rooms to minimize infection risk.
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