A nurse is assessing a client who has refused a surgical procedure. The client states, “I just don’t want to do this,” while appearing anxious and avoiding eye contact when speaking. What is the nurse’s priority action?

Evaluate the client’s understanding of the procedure, its risks, and alternative options.

Document the refusal and notify the primary health care provider.

Ask the unlicensed assistive personnel (UAP) to stay with the client for emotional support.

Reassure the client that the procedure is safe and commonly performed.

Answer and Explanation

The Correct Answer is A

Choice A reason:
The priority action is to assess the client’s understanding of the procedure, including risks, benefits, and alternatives. This ensures informed decision-making and respects client autonomy. Anxiety and avoidance of eye contact suggest that the client may have underlying fears or misunderstandings that need clarification before any documentation or provider notification. This assessment is essential to provide accurate education, support informed consent, and prevent ethical or legal complications.

Choice B reason:
Documenting the refusal and notifying the healthcare provider is important, but it is secondary to ensuring the client fully understands the procedure. Immediate documentation without assessment may neglect the client’s need for education and support, potentially leading to uninformed decisions.

Choice C reason:
Asking a UAP to stay with the client provides emotional support but does not address the client’s knowledge deficit or anxiety related to the procedure. Emotional support is useful after assessing understanding but is not the first priority.

Choice D reason:
Reassuring the client that the procedure is safe ignores the client’s expressed autonomy and may be perceived as coercive. Providing reassurance without assessment may fail to address the client’s underlying concerns and could be ethically inappropriate.

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Correct Answer is C

Explanation

Choice A reason:
Dextrose 2.5% in water is a hypotonic solution once the dextrose is metabolized. Hypotonic fluids cause water to shift into cells, which can lead to cellular swelling. This fluid is not isotonic and is therefore incorrect.

Choice B reason:
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution. It provides free water and promotes fluid movement into cells, making it inappropriate to classify as isotonic.

Choice C reason:
0.9% sodium chloride, also called normal saline, has an osmolality similar to that of plasma. It does not cause significant fluid shifts between compartments and is classified as an isotonic solution. It is commonly used for fluid resuscitation and maintenance of intravascular volume.

Choice D reason:
Dextrose 10% in water is a hypertonic solution. It draws water out of cells into the intravascular space and increases serum osmolality. Because of this effect, it is not isotonic and is an incorrect choice.

A. Assess the client’s vital signs. B. Apply a cool compress to the IV site. C. Remove the IV catheter. D. Notify the healthcare provider.

Correct Answer is C

Explanation

Choice A reason:
Assessing vital signs is important when infection or systemic involvement is suspected; however, the priority is to stop the source of injury. A red streak and warmth along the vein indicate phlebitis, which requires immediate intervention to prevent progression. Vital signs can be assessed after the offending catheter is removed.

Choice B reason:
Applying a cool compress may help relieve inflammation and discomfort associated with phlebitis, but it does not address the underlying cause. Supportive measures should only be implemented after the IV catheter has been discontinued to prevent further vascular irritation.

Choice C reason:
A red streak and warmth along the vein are classic signs of phlebitis. The first and most important action is to remove the IV catheter to prevent further inflammation, tissue damage, or infection. Removing the source of irritation is the priority intervention according to safety and nursing standards.

Choice D reason:
Notifying the healthcare provider may be necessary if complications develop or further treatment is required. However, this is not the first action. Immediate nursing intervention is required to stop the progression of phlebitis before escalation of care.

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A nurse is assessing a client who has refused a surgical procedure. The client states, “I just don’t want to do this,” while appearing anxious and avoiding eye contact when speaking. What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intravenous fluid is classified as an isotonic solution?

Correct Answer is C

Explanation

The nurse assesses the client’s peripheral intravenous (IV) site and observes a red streak on the forearm that is warm to the touch. Which action should the nurse perform first?

Correct Answer is C

Explanation

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