A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

Explain that the treatment is both safe and therapeutic.

Tell the client that the procedure is necessary.

Notify the client's loved ones of the client's refusal of the procedure.

Inform the client they have the right to refuse treatment.

Answer and Explanation

The Correct Answer is D

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

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Correct Answer is B

Explanation

A. The grounding pad is positioned near the client's surgical site: The grounding pad for electrosurgery should be placed on a large, well-vascularized muscle mass away from the surgical site to ensure proper dispersion of electrical current and prevent burns. Placing it near the site increases risk of injury.

B. The client is positioned to minimize pressure on the skin: Proper positioning during surgery helps prevent pressure ulcers and nerve injuries by reducing prolonged pressure on bony prominences and delicate tissues, supporting a safe and therapeutic environment.

C. The client is covered with a cooling blanket during surgery: Maintaining normothermia is critical; cooling blankets can cause hypothermia, which increases the risk of complications such as infection and coagulopathy. Warm blankets or forced-air warming devices are preferred.

D. The client's surgical site is shaved with a razor: Shaving with a razor can cause microabrasions that increase the risk of surgical site infections. Clipping hair with electric clippers is the recommended practice to reduce infection risk.

A. Prick the side of the client's finger. B. Squeeze the client's finger until a blood drop forms. C. Elevate the client's hand above the level of the heart. D. Apply clean gloves. E. Cleanse the client's finger with an iodine swab.

Correct Answer is ["A","D"]

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

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A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

Correct Answer is B

Explanation

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

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