A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
"Not receiving blood will slow down your recovery."
"I understand that you decided not to receive blood products."
"You need to talk with your doctor about this."
"Why are you refusing to receive blood products?"
The Correct Answer is B
Rationale:
A. This response is judgmental and may cause the client to feel guilty or defensive.
B. This response shows empathy and respect for the client's decision.
C. This response may be appropriate if the client needs further information or counseling but should not be the initial response.
D. This response is confrontational and may cause the client to become defensive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
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