A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

Inform the client of the consequences of decreased cerebral circulation.

Initiate a mental health consultation to determine why the client refuses the surgery.

Discuss the client's concerns about having the surgery.

Provide the client with information on additional treatment options.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Informing the client of the consequences of decreased cerebral circulation is premature without understanding the client's specific reasons for refusing the surgery. Jumping to consequences might not address the underlying fears or concerns the client has, potentially leading to increased resistance or anxiety.

Choice B rationale:

Initiating a mental health consultation is a valuable step if the client's refusal appears to be influenced by psychological or emotional factors. However, before involving mental health professionals, it's important for the nurse to engage in a direct conversation with the client to explore their thoughts, fears, and reservations.

Choice C rationale:

Discussing the client's concerns about having the surgery is the most appropriate action in this scenario. Engaging in an open and nonjudgmental conversation allows the nurse to understand the client's perspective, provide information, clarify misconceptions, and address any fears or uncertainties. This approach respects the client's autonomy and promotes shared decision-making.

Choice D rationale:

Providing the client with information on additional treatment options might be premature if the client's main concern is related to the current recommended surgery. It's crucial to first address the client's specific reservations before exploring other treatment possibilities.

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Correct Answer is C

Explanation

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

A. Remind the staff members that this is a breach of confidentiality. B. Discuss the issue with the nurse manager. C. Request that an administrative restriction be placed on the client's record access. D. Prepare a memo for the facility ethics committee.

Correct Answer is A

Explanation

Choice A rationale:

Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.

Choice B rationale:

Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.

Choice C rationale:

Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.

Choice D rationale:

Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.

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A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Correct Answer is C

Explanation

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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