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 C
Explanation
Choice A rationale:
Amputation, although a significant medical history, is not a contraindication to becoming a living kidney donor. The presence of an amputation does not directly impact the person's ability to donate a kidney to their parent.
Choice B rationale:
Primary glaucoma, a condition affecting the eyes, is also not a contraindication to kidney donation. While eye conditions can affect overall health, they do not specifically prevent an individual from donating a kidney if they are otherwise healthy.
Choice C rationale:
Hypertension (high blood pressure) is a contraindication to kidney donation. Individuals with hypertension are at a higher risk of developing kidney disease themselves. Additionally, donating a kidney could exacerbate their condition, potentially leading to further complications. Therefore, this is the correct choice.
Choice D rationale:
Osteoarthritis, a condition affecting the joints, is not a contraindication to kidney donation. Joint problems do not directly impact kidney function or the ability to donate a kidney.
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
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