A nurse is caring for a client who expresses conflicted feelings about undergoing a tubal ligation. Which of the following responses should the nurse make?

"Maybe you should wait to have the procedure."

"This is a common feeling for clients to have before the procedure."

Share more with me about your concerns related to the procedure."

"Why are you concerned about the procedure?"

Answer and Explanation

The Correct Answer is C

A. "Maybe you should wait to have the procedure."

This response may come across as directive and could potentially influence the client's decision. It does not encourage the client to express their feelings or concerns but suggests a specific course of action.

B. "This is a common feeling for clients to have before the procedure."

While it's true that many clients may experience conflicted feelings before undergoing certain procedures, this response is somewhat dismissive. It does not invite the client to explore their specific concerns and may not address the individual nature of the client's feelings.

C. Share more with me about your concerns related to the procedure.

This response encourages the client to express their concerns and provides an opportunity for the nurse to understand the specific issues causing the conflict. It demonstrates empathy and openness, fostering a therapeutic nurse-client relationship. By inviting the client to share more, the nurse can gain insight into the client's emotional and psychological concerns about the tubal ligation.

D. "Why are you concerned about the procedure?"

While this question is an attempt to understand the client's concerns, it may be perceived as too direct or confrontational. The wording might make the client feel defensive or pressured to justify their feelings. The more open-ended phrasing in option C is generally more conducive to therapeutic communication.

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Correct Answer is C

Explanation

A.Notifying the charge nurse is an important action, as it ensures that other team members are aware of the error and can support corrective actions. However, this is not the first action the nurse should take, as assessing the client’s condition takes priority.

B.Informing the provider about the error is essential to allow for any additional orders or corrective measures, such as treatments to mitigate adverse effects. However, the nurse should first assess the client for any changes in condition to report specific findings to the provider if an intervention is needed.

C.Assessing the client’s condition is the first priority when a medication error is discovered. This action helps determine whether the incorrect dose has affected the client, allowing the nurse to provide immediate care if needed.

D.Completing an incident report is necessary to document the error, allowing the facility to review and address any procedural gaps. However, completing the report is not an immediate action in terms of client safety and should occur after assessing the client and notifying the necessary parties.

A. Complete an incident report. B. Receive a hepatitis C immunization. C. Notify the health department. D. Start prophylactic antibiotic therapy

Correct Answer is A

Explanation

A. Complete an incident report.

Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.

B. Receive a hepatitis C immunization:

There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.

C. Notify the health department:

Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.

D. Start prophylactic antibiotic therapy:

Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.

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A nurse is caring for a client who expresses conflicted feelings about undergoing a tubal ligation. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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