A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
"Why don't you want to learn how to give yourself your medication?"
"You will suffer serious health issues if you don't take your medication."
"I'd like to hear your thoughts about giving yourself this medication."
"Have you considered how your decision to refuse medication will affect your family?"
The Correct Answer is C
This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.
The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.
The other options listed are not appropriate actions for the nurse to take in this situation:
- Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
- Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
- Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.
Correct Answer is ["C"]
Explanation
A.Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
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