A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

Reinforce with the client to sleep on the side of the access site.

Obtain the client's blood pressure in either arm.

Encourage the client to increase fluid intake.

Obtain the client's weight.

Answer and Explanation

The Correct Answer is D

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Correct Answer is A

Explanation

A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.
While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.
Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.

A. Veracity B. Countertransference C. Boundary crossing D. Promoting trust

Correct Answer is D

Explanation

Correct answer: D

veracity, in (option A) is incorrect because it refers to telling the truth and being honest with the client. While the nurse's action in obtaining a healthy meal for the client is a positive action, it is not directly related to veracity.

countertransference in (option B) is incorrect because it, refers to the nurse's emotional or personal reaction towards the client that may influence their behaviour or response. It is not applicable to the scenario described.

C. Boundary Crossing happens when a professional line is blurred. In this case, the nurse prioritizes the client's well-being, not a personal connection.

D. Promoting trust involves actions that build rapport, establish a therapeutic relationship, and demonstrate caring and empathy towards the client. By interrupting the bath to obtain a healthy meal for the client, the nurse shows responsiveness to the client's needs, which can enhance trust and confidence in the nurse's care

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A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is D

Explanation

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