A nurse is caring for a client who has acute lymphocytic leukemia. The client is refusing blood products. Which one of the following responses should the nurse take?
“I understand that you decided not to receive blood products.”
“Not receiving blood will slow down your memory”
“Why are you refusing to receive blood products?”
“You need to talk with your doctor about this”
The Correct Answer is A
Choice A Reason:
“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.
Choice B Reason:
“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.
Choice C Reason:
“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.
Choice D Reason:
“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
Choice B Reason:
Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
Choice C Reason:
Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
Choice D Reason:
The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
Correct Answer is A
Explanation
Choice A Reason:
Questioning the client about allergies before the procedure is appropriate. It is essential to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is crucial to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.
Choice B Reason:
Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.
Choice C Reason:
Evaluating the client for claustrophobia is inappropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.
Choice D Reason:
Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.
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