A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?
"Why are you changing your mind about the procedure?"
"This procedure is perfectly safe."
"I will contact the provider to let her know."
"You should discuss your concerns with your family!"
The Correct Answer is C
A. "Why are you changing your mind about the procedure?" This question may come across as confrontational or judgmental. It does not directly address the client’s need for information or support.
B. "This procedure is perfectly safe." This response is dismissive and provides false reassurance. The nurse should avoid minimizing the client's concerns.
C. "I will contact the provider to let her know." When a client expresses uncertainty about undergoing a procedure, the nurse's priority is to notify the provider. The provider is responsible for addressing the client’s concerns, clarifying the procedure, and ensuring informed consent. The client's autonomy must be respected, and they have the right to withdraw consent at any time.
D. "You should discuss your concerns with your family!" While family support can be helpful, the decision to proceed or not is ultimately between the client and the provider. Directing the client to the family may undermine their autonomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the nurse manager: Informing the manager may be necessary later, but the immediate priority is assessing and addressing the family member's condition.
B. Check the family member's vital signs: Assessing the family member's condition is the first step to determine the severity of the situation and provide appropriate care.
C. Obtain the family member's health history: Health history is valuable but not a priority in an acute event like fainting.
D. Complete an incident report: Incident reporting is necessary but should occur after the situation is managed and the family member's condition is stabilized.
Correct Answer is C
Explanation
A. Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B. Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C. Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D. Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.
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