A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse about what the provider might be planning to do. Which of the following nursing responses should the nurse make?
Provide the client with articles from the internet that explain colon cancer stages.
Encourage the client to write down questions to ask the provider.
Explain the various options available for treatment based on the cancer stage.
Assure the client that the provider will explain what has been planned.
The Correct Answer is B
Choice A reason: Providing the client with articles from the internet that explain colon cancer stages is not the best approach. While it is important for the client to understand their condition, the nurse should ensure that the information is accurate and tailored to the client’s specific situation. Additionally, the nurse should facilitate a direct conversation between the client and the healthcare provider to address any questions or concerns.
Choice B reason: Encouraging the client to write down questions to ask the provider is an excellent approach. This empowers the client to actively participate in their care and ensures that they have a clear understanding of their diagnosis and treatment options. It also helps the client to remember important questions during their consultation with the provider.
Choice C reason: Explaining the various options available for treatment based on the cancer stage is not within the nurse’s scope of practice. Detailed discussions about treatment options should be conducted by the healthcare provider, who has the expertise to provide accurate and comprehensive information tailored to the client’s specific medical condition.
Choice D reason: Assuring the client that the provider will explain what has been planned is a supportive response, but it does not actively engage the client in their care. While it is important to reassure the client, the nurse should also encourage the client to prepare questions and participate in discussions with the provider to ensure they fully understand their treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.
Choice B reason:
A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.
Choice C reason:
A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.
Correct Answer is A
Explanation
Choice A reason:
Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.
Choice B reason:
Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.
Choice C reason:
Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.
Choice D reason:
Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.
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