A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?

Inform the client that this procedure is the only option they have for treatment.

Reinforce and clarify the information provided by the surgeon with the client.

Terminate the conversation and state. "It's too late to cancel the procedure."

Delay the procedure and enlist additional staff to persuade the client to have the procedure.

Answer and Explanation

The Correct Answer is B

A. It is important to provide the client with all options available, including risks, benefits, and alternatives to the surgery. Telling the client that the procedure is the only option may limit their autonomy and decision-making ability.

B. The nurse should reinforce the information already provided by the surgeon and clarify any questions the client may have. This ensures that the client is fully informed and can make an educated decision about their care. Encouraging open communication helps the client feel more comfortable with their decision.

C. This response disregards the client’s right to make decisions about their own care. The client must be given the opportunity to express concerns and make an informed choice about their treatment.

D. Persuading the client to undergo surgery is not appropriate. The nurse should support the client’s decision-making process, providing clear and accurate information while respecting their autonomy. Coercion is unethical and does not align with patient-centered care.

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Correct Answer is C

Explanation

A. "I had symptoms of asthma when I was a child.": Childhood asthma is not a significant concern in end-stage liver disease or transplant eligibility. It does not have a direct impact on the client’s current health status or the potential success of the liver transplant.

B. "My parent has type 2 diabetes mellitus.": While family medical history is relevant, having a parent with type 2 diabetes mellitus is not a contraindication for liver transplantation. The client’s own health status and adherence to medical care are more important.

C. "I am not very good about taking prescribed medication.": Post-transplant care requires strict adherence to medications, especially immunosuppressive drugs, to prevent organ rejection. If the client has a history of nonadherence, this can jeopardize the success of the transplant.

D. "I wish my family was more supportive of my decision.": This statement pertains to psychosocial concerns and can be addressed with counseling or support services. It does not pose an immediate medical concern for the transplant process.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Instruct the client to rise slowly from a sitting position: The client is showing signs of orthostatic hypotension, with a drop in blood pressure when changing positions. Providing instructions to rise slowly helps prevent dizziness and potential falls, especially in the presence of anemia-related fatigue and reduced oxygen delivery.
Evaluate a stool sample for occult blood: The client has anemia (Hgb 8 g/dL, Hct 24%) and is taking naproxen, a nonsteroidal anti-inflammatory drug (NSAID) known to cause gastrointestinal bleeding. Occult GI blood loss is a common cause of iron deficiency anemia in such clients. Identifying hidden bleeding is a priority to determine the cause of anemia.

Rationale for Incorrect Choices:

Draw a blood sample for arterial blood gases: There is no evidence of acute respiratory distress or hypoxemia requiring blood gas analysis. The client’s oxygen saturation is 94% on room air, and breath sounds are clear, making this action unnecessary at this time.
Perform a 12-lead ECG: Although the client has tachycardia (HR 108/min), this is likely a compensatory response to anemia. Without chest pain or other signs of cardiac compromise, a 12-lead ECG is not the most immediate action.
Administer an inhaled bronchodilator: The client reports dyspnea with exertion, but there is no indication of bronchospasm or wheezing. Breath sounds are clear bilaterally, so a bronchodilator is not indicated and would not address the underlying issue of anemia.

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A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

Correct Answer is C

Explanation

A nurse in a provider's office is caring for a client. Exhibits Complete the following sentence by using the lists of options. The first action the nurse should take is dropdownfollowed bydropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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