A nurse is planning care for a client during Ramadan who is a devout Muslim. Which of the following actions should the nurse include regarding the client's diet?

Ensure that pork is included in the evening meal.

Schedule for meals to be served after sundown.

Avoid red meat in the client's meals.

Wait 1 hr after the client consumes dairy to serve poultry.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Ensure that pork is included in the evening meal: Pork and pork-derived products are prohibited in Islam due to religious dietary laws. Serving pork would be culturally inappropriate and could cause distress to the client, as it violates halal dietary practices.

B. Schedule for meals to be served after sundown: During Ramadan, Muslims fast from dawn to sunset, abstaining from food and drink during daylight hours. Scheduling meals after sundown aligns with their religious observance and supports cultural sensitivity and nutritional needs.

C. Avoid red meat in the client's meals: Islam does not prohibit the consumption of red meat as long as it is halal-slaughtered. There is no religious requirement during Ramadan to avoid red meat, so this action is unnecessary unless restricted for other health reasons.

D. Wait 1 hr after the client consumes dairy to serve poultry: This practice is not part of Islamic dietary rules and is not relevant to Ramadan fasting. It has no religious basis and would not address the specific dietary considerations for a devout Muslim during Ramadan.

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Correct Answer is C

Explanation

A. "I cannot be a witness for your consent to donate.": While a nurse often cannot witness the consent form to avoid a conflict of interest, this response does not directly address the client’s need for information about how to become an organ donor.

B. "Your name cannot be removed once you are listed on the organ donor list.": Clients can change their decision about organ donation at any time, and their name can be removed from the registry if they choose.

C. "Your desire to be an organ donor must be documented in writing.": Documenting consent in writing ensures legal clarity and verifies the client’s intent. Written consent is required to formalize organ donation in the medical record or donor registry.

D. "You must be at least 21 years of age to become an organ donor.": Age requirements for organ donation vary by jurisdiction, and many states allow individuals younger than 21 to register as donors, often with parental consent if under 18.

A. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg. B. Obtain the first unit of packed RBCs from the blood bank. C. Document the blood product transfusion in the client's medical record. D. Stay with the client for the first 15 min of the transfusion. E. Start an IV bolus of lactated Ringer's solution.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Rationale for indicated actions:

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.

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A nurse is planning care for a client during Ramadan who is a devout Muslim. Which of the following actions should the nurse include regarding the client's diet?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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