A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?
"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."
Clients over the age of 65 must have a saline lock according to facility policy."
"It is quicker to administer medications intravenously in the hospital."
"We administer all medications intravenously to clients in this unit.
The Correct Answer is A
A. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours.": This response directly explains the medical reason for the saline lock, linking it to the client’s prescribed therapy. It provides clarity and reinforces that the intervention is necessary for safe and effective treatment.
B. "Clients over the age of 65 must have a saline lock according to facility policy.": Age alone is not a valid reason for IV access. Using such an explanation could reduce trust between the nurse and the client.
C. "It is quicker to administer medications intravenously in the hospital.": While IV administration can be faster, this response is vague and does not address why this particular client specifically requires a saline lock. It lacks individualized rationale.
D. "We administer all medications intravenously to clients in this unit.": Not all medications are given intravenously. Providing this explanation would confuse the client and reflect poor communication of actual care needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use nonverbal gestures to assure the client that the procedure is safe and will help him: Nonverbal gestures may provide comfort but cannot effectively convey detailed information about a therapeutic procedure, risks, or consent.
B. Tell the client that he will receive written information in his language after the procedure: Providing written materials after the procedure does not allow the client to give informed consent beforehand. Teaching must occur prior to the procedure to ensure comprehension.
C. Have a medical interpreter present during the teaching: Using a professional medical interpreter ensures accurate, clear communication regarding the procedure, its risks, benefits, and alternatives. This approach promotes informed consent and respects the client’s autonomy while minimizing miscommunication.
D. Ask a family member to translate: Family members may introduce bias, omit details, or misunderstand medical terminology, which can compromise informed consent. Professional interpreters are preferred to maintain accuracy, confidentiality, and safety during education.
Correct Answer is D
Explanation
A. Dorsal surface of the hand: In clients with dark skin, the pigmentation may mask subtle color changes such as cyanosis. The hands are not reliable assessment sites for detecting oxygenation problems in this population.
B. Dorsal surface of the foot: Similar to the hands, the feet have thicker skin and more pigmentation, which makes detecting cyanosis difficult. Peripheral sites are less accurate for identifying central cyanosis in dark-skinned clients.
C. Pinnae of the ears: The ears may show some color changes, but due to pigmentation and poor visibility, they are not the most accurate location for detecting cyanosis in dark-skinned individuals.
D. Conjunctivae: The mucous membranes, such as the conjunctivae, lips, and oral mucosa, provide the most reliable sites for assessing cyanosis in dark-skinned clients. These areas are less affected by skin pigmentation and reflect changes in oxygenation more clearly.
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