Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?
A. "If I were you, I would contact your spiritual director."
B. "You have a right to change your mind."
"You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
C. "Making this decision is wrong."
D. "I'm sure that everything will be all right, regardless of your decision."
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
Similar Questions
A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hr creatinine clearance test. Which of the following statements should the nurse include in the teaching?
A. "You can begin collection of urine after discarding your first morning void."
The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
B. "You should eat a protein-rich diet during the collection period."
C. "You can cleanse your perineal area with an antiseptic towel each time before you void."
D. "You should record your blood glucose level each time you void."
Full Explanation
The correct answer is A. The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
A. The client fell because the assistive personnel did not place nonskid slippers on the client."
B. The client does not appear to have any injuries resulting from the fall."
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
D. "An incident report has been completed and sent to risk management."
Full Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?
A. Apply pressure to the lacrimal punctum after administering the drops.
The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.
B. Position the child side-lying on the bed before administering the drops.
C. Flush the eye with normal saline solution before administering the drops
D. Wipe from the outer to the inner canthus after administering the drops.
Full Explanation
The correct answer is A. The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.