Nokea
A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?
- A. "I believe in this case you should make an exception and accept the blood transfusion."
- B. "I know your family would approve of your decision to have a blood transfusion."
- C. "Why does your religion mandate that you cannot receive any blood transfusions?"
- D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."
Correct Answer: D
Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.
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An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct Answer: D
Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.
A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
- A. Insert an implanted port
- B. Close a laceration with sutures
- C. Place an endotracheal tube
- D. Initiate an enteral feeding through a gastrostomy tube
Correct Answer: D
Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.
A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the nurse monitor for in this client?
- A. Increased appetite
- B. Dry mouth
- C. Nausea and vomiting
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. Beta-blockers are known to decrease heart rate, which can lead to bradycardia. This is a common side effect that nurses should monitor for in clients taking beta-blockers. Choices A, B, and C are incorrect because increased appetite, dry mouth, nausea, and vomiting are not typical side effects associated with beta-blockers. Therefore, the nurse should focus on monitoring for bradycardia in this client.
A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 400 mL/hr
- B. 200 mL/hr
- C. 300 mL/hr
- D. 250 mL/hr
Correct Answer: A
Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.
When working with a client who does not speak the same language as the nurse and an interpreter is present, which of the following actions should the nurse take?
- A. Talk directly to the client, instead of the interpreter, when speaking.
- B. Speak loudly to the interpreter.
- C. Use gestures to communicate with the client.
- D. Avoid using an interpreter and rely on family members.
Correct Answer: A
Rationale: When caring for a client who speaks a different language, it is essential to communicate through an interpreter. Talking directly to the client, rather than the interpreter, ensures clear and respectful interaction. Speaking loudly to the interpreter (choice B) is not necessary and may be perceived as disrespectful. Using gestures (choice C) alone may lead to misunderstandings or misinterpretations. Avoiding the use of an interpreter and relying solely on family members (choice D) can compromise the accuracy and confidentiality of the communication.