A nurse is caring for a client who is postoperative following an appendectomy.
Vital Signs
1800:
Temperature 98.4° F (36.8° C) Heart rate 104/min
Respiratory rate 22/min
Blood pressure 142/80 mm Hg
O2 saturation 97% on room air
1800:
Client alert and oriented x 4
Skin warm and dry
Lungs clear on auscultation
Bowel sounds hypoactive in all four quadrants Urine clear yellow
Incisional dressing clean and dry
Client reports pain as 6 on a scale of 0 to 10
1815:
Morphine administered as prescribed
2000:
Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min
Blood pressure 158/88 mm Hg O2 saturation 93% on room air
Which of the following 4 client findings should the nurse report to the provider?
Bowel sounds
Oxygen saturation
Nausea
Vomiting
Pain level
Heart rate
Incision characteristics
Lungs sounds
Correct Answer : B,D,E,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidence-based information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"}}
No explanation
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