A nurse manager is planning a staff in-service to address advocacy in client care.
The nurse should promote which of the following practices during the in-service? (Select all that apply.)
Making decisions about health care on clients' behalf.
Promoting health care access.
Encouraging clients to seek further information from the provider.
Addressing client needs when providing resources.
Honoring family requests to withhold medical information.
Correct Answer : B,C,D
Choice A rationale:
Making decisions about health care on clients' behalf without their involvement violates the principle of patient autonomy. Patients have the right to be actively involved in decisions about their own care and treatment plans. Encouraging shared decision-making and respecting patients' choices are essential aspects of nursing advocacy.
Choice B rationale:
Promoting health care access is a fundamental aspect of advocacy in client care. Nurses should advocate for their patients' access to necessary healthcare services, treatments, and resources. This includes ensuring that patients have access to appropriate medical facilities, specialists, medications, and therapies. Advocating for health care access helps patients receive timely and appropriate care, improving their overall health outcomes.
Choice C rationale:
Encouraging clients to seek further information from the provider is crucial for informed decision-making. Providing patients with accurate and relevant information enables them to make educated choices about their health. Nurses can facilitate this process by clarifying medical information, explaining treatment options, and addressing patients' concerns. Informed patients are better equipped to actively participate in their care and advocate for their own needs.
Choice D rationale:
Addressing client needs when providing resources is an essential aspect of nursing advocacy. Nurses should assess their patients' individual needs and collaborate with other healthcare professionals to provide appropriate resources and support. This can include coordinating social services, arranging for home healthcare, or connecting patients with support groups. Meeting clients' needs ensures that they receive comprehensive care, promoting their overall well-being.
Choice E rationale:
Honoring family requests to withhold medical information can be ethically challenging. While family members play a significant role in a patient's life, confidentiality and patient autonomy must be respected. In most cases, healthcare providers should prioritize communicating directly with the patient, respecting their right to make decisions about their own health information. Exceptions may arise in situations involving legal guardianship or when patients are unable to communicate their preferences. However, the default approach should be to involve the patient directly in decisions about their healthcare information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is **a. Observe for bruising of the skin.**
Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.
Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.
Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.
Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.
Correct Answer is D
Explanation
The correct answer is D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
Choice A reason: Storing a unit of blood at room temperature for 1 hour prior to the infusion is not recommended. Blood products should be kept refrigerated until just before the transfusion to minimize the risk of bacterial contamination. The recommended storage temperature for packed RBCs is 1-6°C. If blood is left at room temperature, it should be infused within 30 minutes to ensure safety.
Choice B reason: Ensuring that the transfusion is completed within 6 hours is not correct. The standard practice is to complete a blood transfusion over 2 to 4 hours, depending on the volume and the patient’s condition. This is to reduce the risk of bacterial growth and transfusion reactions. Prolonging the transfusion time beyond 4 hours increases the risk of bacterial contamination and can compromise the efficacy of the transfused red blood cells.
Choice C reason: Obtaining venous access using a 22-gauge needle is not ideal for a transfusion of packed RBCs. A larger bore needle, typically an 18-gauge or 20-gauge, is preferred to ensure adequate flow of the viscous packed RBCs and to prevent hemolysis. The smaller the gauge number, the larger the needle diameter, so a 22-gauge needle might be too small and could damage the red blood cells during the transfusion.
Choice D reason: Using a solution of 0.9% sodium chloride to flush the transfusion tubing is the correct action. Normal saline is isotonic and is the only fluid compatible with packed RBCs. It is used to prime the transfusion set and to flush the line before and after the transfusion to prevent hemolysis and clotting within the tubing.
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