A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?
"If I were you, I would contact your spiritual director."
"You have a right to change your mind."
"Making this decision is wrong."
"I'm sure that everything will be all right, regardless of your decision."
The Correct Answer is B
The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This is a mild analgesic and antipyretic. It may be inadequate for moderate pain such as that from cholelithiasis (gallstones).
Choice B reason:
Omeprazole Omeprazole should not administer because it is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. It is not indicated for the treatment of pain and discomfort associated with cholelithiasis.
Choice C reason
Should not be administered
Metoclopramide Metoclopramide should not be administered because it is a medication used to treat gastrointestinal issues such as nausea, vomiting, and gastroparesis. It is not indicated for the treatment of pain associated with cholelithiasis.
Choice D reason:
Ketorolac: This is a nonsteroidal anti-inflammatory drug (NSAID) appropriate for moderate to severe pain, including biliary colic due to cholelithiasis. It is often used PRN for acute pain relief.
Correct Answer is ["D","E"]
Explanation
Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Urine output 40 mL in the last hour:Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.
Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.
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