A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?

"Do you need information on hospice care?"

"Would you like to talk to a counselor about advance directives?"

"Would you like to speak to a spiritual advisor?"

"Do you need a prescription for an antianxiety medication?"

None

Answer and Explanation

The Correct Answer is C

A.   While hospice care may be appropriate for the client, it does not directly address the client's reported depression.
B.   Discussing advance directives is important for end-of-life care planning, but it may not address the client's current emotional needs.
C.   Offering spiritual support acknowledges the client's emotional distress and provides an opportunity for comfort and guidance that aligns with the client's values and beliefs.
D.   Offering medication without further assessment or exploration of the client's feelings may not be the most therapeutic response to the reported depression.

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Correct Answer is A

Explanation

A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.

A. Administer the blood via a 21-gauge IV needle. B. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion. C. Check the client's vital signs from the previous shift prior to the initiation of the transfusion. D. Set the IV infusion pump to administer the blood over 6 hr.

Correct Answer is B

Explanation

A. A larger-bore needle (usually 18- to 20-gauge) is recommended for blood transfusions to prevent hemolysis and ensure adequate flow rate.
B. Flushing the tubing with 0.9% sodium chloride ensures that it is primed and free from air or any incompatible solutions before starting the blood transfusion.
C. Vital signs should be checked immediately before, during, and after the transfusion to monitor for adverse reactions.
D. Blood transfusions are typically completed over 2 to 4 hours, depending on the clinical context, to reduce the risk of complications.

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A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

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