A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." Which of the following responses should the nurse make?
"You have the right to refuse the procedure."
"We can manage your care following the procedure without complications."
"Your doctor thinks this surgery is necessary."
"Let me review the procedure so you can understand what is going to happen."
The Correct Answer is A
A. "You have the right to refuse the procedure.": Clients have the legal and ethical right to refuse treatment at any time, including surgery. Acknowledging this respects the client’s autonomy and supports informed decision-making.
B. "We can manage your care following the procedure without complications.": This statement minimizes the client’s concerns and may be perceived as coercive. It does not address the client’s right to make an informed choice.
C. "Your doctor thinks this surgery is necessary.": Referencing the provider’s opinion without exploring the client’s concerns does not respect the client’s autonomy and may increase anxiety or pressure to comply.
D. "Let me review the procedure so you can understand what is going to happen.": While providing information is helpful, the client has already expressed refusal. This approach may be more appropriate if the client is undecided, but it does not acknowledge their right to decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "I will hang a pastel-colored mobile 24 inches above my baby's crib.": Newborns can only see objects clearly 8–12 inches away and are more attracted to bold patterns and contrasting colors. A mobile 24 inches away would be too far for visual stimulation.
B. "I will place a ticking clock nearby to soothe my baby throughout the day.": Rhythmic sounds, such as a ticking clock, can mimic the intrauterine environment and help calm newborns. This is an appropriate soothing technique for a 1-week-old.
C. "I will avoid picking up my baby too often to keep from spoiling him.": Holding and responding promptly to a newborn’s needs promotes bonding, emotional security, and healthy development. At this age, infants cannot be spoiled.
D. "I can use a firm pillow to prop up the bottle when feeding my baby.": Propping bottles increases the risk of choking, aspiration, and otitis media. Infants should always be held during feedings for safety and bonding.
Correct Answer is B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
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