A nurse is caring for a client who is scheduled for a bronchoscopy. The client states, "I no longer wish to have this procedure." Which of the following responses should the nurse make?
"Why have you changed your mind about the procedure?"
"You have the right to refuse the procedure."
"Have you had any troubles with swallowing?
"Your doctor wants you to have this procedure."
The Correct Answer is B
Rationale:
A. "Why have you changed your mind about the procedure?": Asking “why” can feel confrontational and may pressure the client to justify their decision rather than respecting their autonomy. It’s better to acknowledge their feelings without judgment.
B. "You have the right to refuse the procedure.": Affirming the client’s right to refuse respects their autonomy and legal rights. It opens the door for further discussion and ensures informed consent is voluntary and ongoing.
C. "Have you had any troubles with swallowing?": This question is unrelated to the client’s decision to refuse the bronchoscopy and does not address their expressed concern or right to refuse.
D. "Your doctor wants you to have this procedure.": Emphasizing the provider’s wishes may pressure the client and undermine their autonomy. The nurse’s role is to support informed decision-making, not to coerce.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.
B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.
C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.
D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.
Correct Answer is ["31"]
Explanation
Calculation:
Total volume to be infused = 500 mL.
- Convert the infusion time from hours to minutes.
Infusion time = 4 hr × 60 min/hr
= 240 min.
Drop factor = 15 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 15 gtt/mL) / 240 min
= 7500 gtt / 240 min
= 31.25 gtt/min.
Rounded to the nearest whole number:
= 31 gtt/min.
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