A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

"Why do you think your life is over?"

"Would you like to meet with another client who is an amputee?"

"Most people can adjust following this surgery."

"You are upset. We can talk about this later."

Answer and Explanation

The Correct Answer is B

Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.

Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.

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Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

A. Administer oxygen to the client. B. Collect a urine sample. C. Check the client's vital signs. D. Stop the infusion.

Correct Answer is D

Explanation

The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.

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A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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