What is the nurse’s best initial response if a client refuses surgery after an embolectomy?

Correct Answer: A

Rationale: The correct initial response is A: Explain the risks of not having the surgery. This is crucial to ensure the client fully understands the consequences of refusing the surgery. It allows the nurse to address any concerns or misconceptions the client may have, enabling an informed decision-making process. Notifying the physician immediately (B) may be necessary but should follow after attempting to provide education. Notifying the nursing supervisor (C) is not the priority in this situation. Recording the client’s refusal in the nurses’ notes (D) is important but should not be the first action taken.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. The cuff size should be appropriate to ensure accurate readings. 2. A cuff that is too small can result in falsely elevated readings. 3. A cuff that is too large can lead to falsely low readings. 4. Placing the cuff 1 cm above the brachial artery ensures proper placement for accurate measurements. Other Choices: A: The nurse should make sure that the cuff is deflated fully - Incorrect. The cuff should be inflated fully for accurate readings. B: then immediately start the second reading for the same client - Incorrect. It is important to wait a few minutes between readings to allow the blood vessels to recover. C: The nurse should release the valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second - Incorrect. The pressure should be released at a steady rate, not specific to 2-3 mmHg per second.

Correct Answer: B

Rationale: The correct answer is B: Remove dead skin cells and debris. Wet-to-dry dressings help in debriding the wound by promoting the removal of dead tissue and debris when the dressing is changed. This process aids in creating a clean wound bed, which is essential for proper wound healing. The other choices are incorrect because wet-to-dry dressings are not primarily used to prevent wound infections (A), absorb blood and drainage (C), or protect the skin from injury (D). These functions may be achieved through other types of dressings or wound care methods.

Correct Answer: C

Rationale: Correct Answer: C Rationale: The client is experiencing signs of a transfusion reaction, likely due to a blood type incompatibility. Running normal saline at a keep-vein-open rate helps maintain the client's circulation and blood pressure while stopping the transfusion. This step is crucial to prevent further complications and stabilize the client's condition. Summary of Other Choices: A: Removing the IV line may worsen the situation as it can lead to air embolism or abrupt changes in fluid balance. B: Running a solution of 5% dextrose in water is not the appropriate intervention for a transfusion reaction and does not address the underlying issue. D: Obtaining a culture of the catheter tip is not a priority in this acute situation and does not directly address the client's immediate needs.

Correct Answer: C

Rationale: The correct answer is C: Relieve respiratory distress due to bronchial spasm. Epinephrine is a bronchodilator that helps to open up the airways and relieve respiratory distress in conditions like asthma or anaphylaxis. It is not indicated for reducing anaphylaxis (choice A) as it is used to treat anaphylaxis itself. It does not relieve hypersensitivity to allergen (choice B) as it does not address the underlying allergic response. Epinephrine also does not restore cardiac rhythm (choice D), as it is used for treating respiratory issues, not cardiac arrhythmias.