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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 case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. If there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A is the correct choice because it acknowledges the client's interest in alternative therapies and offers to review information to help select a safe practitioner. This response shows support for the client's autonomy and involves them in the decision-making process. It also ensures the client's safety by emphasizing the importance of selecting a reputable practitioner.
Incorrect Choices:
B: This choice assumes the provider will automatically inform the client about therapies, which may not always be the case. It does not actively involve the client in their care.
C: While it supports the client's autonomy, it lacks guidance on selecting a safe practitioner and may not prioritize the client's safety.
D: Suggesting online support groups for remedies may not ensure the safety or efficacy of the therapies, and it does not involve professional guidance.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning.
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is essential as it considers the client's level of participation and promotes independence. Assessing the client's ability to assist ensures safety and prevents injury during repositioning. It also promotes client-centered care by involving the client in their own care.
Choice B is incorrect because repositioning without assistive devices may not be safe or effective, especially for a stroke client who may have limited mobility.
Choice C is incorrect because raising the side rails does not address the client's ability to help with repositioning. It may provide some safety measures but does not actively involve the client in the process.
Choice D is incorrect as discussing preferences for a repositioning schedule does not address the immediate need to evaluate the client's ability to assist with repositioning.
Overall, choice A is the most appropriate as it prioritizes the client's safety, independence, and active participation in their care.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.