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A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should reflect on their own beliefs and values to ensure they can provide unbiased care. This step is essential to maintain professionalism and respect for the parents' autonomy. It allows the nurse to approach the situation with empathy and understanding.
B: Telling the parents that the procedure is necessary may come off as dismissive of their beliefs and could create conflict.
C: Informing the parents that staff does not require their consent is unethical and goes against the child's and parents' rights. It disregards their autonomy.
D: Contacting a spiritual support person may be helpful, but it should not be the first step. The nurse should first address their own values and then involve spiritual support if needed.
In summary, option A is the best course of action as it promotes respectful and patient-centered care.
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A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes.
- B. Use synthetic fabrics for the client's bedding.
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is highly flammable and can pose a serious risk when in contact with oxygen therapy equipment. It is crucial to prevent any potential sources of ignition near oxygen therapy to ensure the safety of the client.
Incorrect choices:
A: Apply petroleum jelly to soothe the mucous membranes - Petroleum jelly is flammable and should not be used near oxygen therapy.
B: Use synthetic fabrics for the client's bedding - The type of bedding material is not directly related to home oxygen therapy.
C: Clean the equipment with an alcohol-based cleaning product - Alcohol-based products are flammable and should be avoided around oxygen therapy equipment.
A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed.
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed.
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and comfort. Sitting next to the client also creates a more intimate and open environment for communication. Standing at the side or foot of the bed may make the client feel intimidated or uncomfortable. Sitting on the bed with the client can invade personal space and may not be professional. In summary, sitting in a chair next to the bed is the most appropriate position for the nurse to establish a therapeutic and trusting relationship with the client on bedrest.