A nurse is caring for a client who is near the end of life and is on complete bed rest.
The client states that he needs to have a bowel movement and the nurse offers a bedpan.
The client states, "I've always used the bathroom." Which of the following responses should the nurse make?
"Tell me what concerns you have about using a bedpan."
"Make sure to use nearby furniture to support yourself when walking to the bathroom."
"You have to use the bedpan for your own safety."
"I will have the physical therapist ambulate you to the bathroom." .
The Correct Answer is A
Choice A rationale:
The nurse should prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.
Choice B rationale:
This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.
Choice C rationale:
This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.
Choice D rationale:
Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.
Choice B rationale:
Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.
Choice C rationale:
White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.
Choice D rationale:
Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.
Correct Answer is B
Explanation
The correct answer is choice b. “I will hang a new bag of TPN and IV tubing every 24 hours.”
Choice A rationale:
Monitoring the client’s blood glucose level every 8 hours is important, but it is not the best indicator of understanding the TPN procedure. Blood glucose levels should be monitored regularly, but the frequency can vary based on the client’s condition and physician’s orders.
Choice B rationale:
Hanging a new bag of TPN and IV tubing every 24 hours is correct. This practice helps prevent infection and ensures the client receives the correct formulation of nutrients.
Choice C rationale:
Increasing the rate of the TPN infusion to ensure the correct amount is given is incorrect. The rate of TPN infusion should be strictly controlled and adjusted only by a physician’s order to prevent complications such as hyperglycemia or fluid overload.
Choice D rationale:
Obtaining the client’s weight every other day is important for monitoring nutritional status, but it does not directly indicate an understanding of the TPN procedure. Daily weights are often recommended to closely monitor the client’s response to TPN.
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