A nurse is caring for a client who has acute lymphocytic leukemia. The client is refusing blood products. Which one of the following responses should the nurse take?

“I understand that you decided not to receive blood products.”

“Not receiving blood will slow down your memory”

“Why are you refusing to receive blood products?”

“You need to talk with your doctor about this”

Answer and Explanation

The Correct Answer is A

Choice A Reason:

“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.

Choice B Reason:

“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.

Choice C Reason:

“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.

Choice D Reason:

“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.

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Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:

Wiping the eyes from the outer to the inner canthus is inappropriate. This direction of wiping might risk introducing contaminants into the eyes. It's generally advised to wipe from the inner to the outer canthus to minimize the risk of introducing potential eye irritants.

Choice B Reason:

Applying eye patches over the eyes if the eyelids do not close completely is appropriate. Eye patches help protect the eyes from potential damage, dryness, or exposure to light if the eyelids do not close fully.

Choice C Reason:

Cleansing the eyes with a chlorhexidine solution is inappropriate. Chlorhexidine solution might be too harsh for use around the delicate eye area and could cause irritation or damage to the eyes. Using a gentler and specifically formulated eye cleansing solution or sterile saline is usually recommended for eye care.

Choice D Reason:

Placing moist compresses over the eyes every 2 to 4 hours is appropriate. Moist compresses can help maintain moisture and prevent dryness in the eyes, reducing the risk of corneal damage due to the inability to blink.

Choice E Reason:

Instilling lubricating eye drops into the lower lid of each eyeis appropriate. Lubricating eye drops help prevent dryness and maintain eye moisture, offering protection to the cornea.

A. To an insurance agency in regard to a life insurance policy B. To a medical interpreter service on behalf of a client C. To a family member when the client is not available D. To an employer for a pre-employment screening

Correct Answer is B

Explanation

Choice A Reason:

To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.

Choice B Reason:

To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.

Choice C Reason:

To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.

Choice D Reason:

To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.

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A nurse is caring for a client who has acute lymphocytic leukemia. The client is refusing blood products. Which one of the following responses should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is B

Explanation

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