A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
Countertransference
Boundary crossing
Promoting trust
Veracity
The Correct Answer is C
A. Incorrect. Countertransference refers to the nurse's emotional reaction to the client based on the nurse's personal feelings or past experiences.
B. Incorrect. Boundary crossing refers to the nurse's actions that blur the professional boundaries of the nurse-client relationship, and this action does not necessarily represent boundary-crossing.
C. Correct. The nurse's action of interrupting the bath to obtain a healthy meal for the client demonstrates an immediate response to the client's need and promotes trust and rapport between the nurse and the client.
D. Incorrect. Veracity refers to truthfulness and honesty, but it does not directly apply to the nurse obtaining a meal for the client who is hungry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Placing the client in a supine position may impede drainage and is not recommended for a client with a chest tube.
B. Correct. Ensuring that the chest tube drainage system is kept below the level of the client's chest allows for proper drainage of fluid and prevents backflow of drainage into the client's chest.
C. Incorrect. The collection chamber should be emptied as needed to prevent overfilling, which could obstruct drainage.
D. Incorrect. Clamping the chest tube is not indicated for a client with a chest tube set to continuous suction, as it would interfere with the function of the drainage system.
Correct Answer is D
Explanation
A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.
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