A nurse is caring for a client who states, "I don't want to start dialysis treatments." Which of the following responses should the nurse make?

"I'm sorry to hear that, but I know the dialysis will make you feel better."

"What are your concerns about the dialysis treatments?"

"Do you think your doctor would have recommended dialysis if you didn't need it?"

"Most people do get tired of dialysis treatments after a while.”

Answer and Explanation

The Correct Answer is B

A. "I'm sorry to hear that, but I know the dialysis will make you feel better.": This response dismisses the client’s feelings and moves too quickly to reassurance without first exploring the client’s perspective. It can make the client feel unheard and pressured to accept the treatment.

B. "What are your concerns about the dialysis treatments?": This response encourages open communication by inviting the client to express their fears, concerns, or misunderstandings. It shows respect for the client's autonomy and fosters a therapeutic relationship built on trust and understanding.

C. "Do you think your doctor would have recommended dialysis if you didn't need it?": This shifts focus away from the client’s feelings and places undue emphasis on the authority of the provider. It may make the client feel invalidated or coerced rather than supported in making an informed decision.

D. "Most people do get tired of dialysis treatments after a while.": This statement reinforces negative feelings about dialysis and can increase the client’s anxiety or resistance toward the treatment rather than helping them work through their concerns in a constructive manner.

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Correct Answer is C

Explanation

A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.

B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.

C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.

D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.

A. Oxygen saturation 95% B. Respiratory rate 14/min C. Urinary output 160 mL/8hr D. Blood pressure 108/58 mm Hg

Correct Answer is C

Explanation

A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.

B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.

C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.

D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.

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A nurse is caring for a client who states, "I don't want to start dialysis treatments." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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