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”

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.

Choice B Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice C Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice D Reason:

Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.

A. Open the innermost lower flap of the sterile kit while standing away from the sterile field. B. Open each side flap of the sterile kit individually while pulling to the side. C. Open the outside cover of the sterile kit and remove the dust cover. D. Grasp the outermost flap of the sterile kit while opening away from the body. E. Prepare a dry work surface above the waist level.

Correct Answer is E,C,D,B,A

Explanation

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Correct Answer is E,C,D,B,A

Explanation

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