A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

The client will verbalize 3 positive attributes about themselves by day 3

The client will perform personal hygiene with no prompting

The client will attend group by day 2

The client will remain free from injury for duration of their hospitalization

Answer and Explanation

The Correct Answer is D

A. The client will verbalize 3 positive attributes about themselves by day 3. This is a good long-term goal but does not directly prevent self-harm.

B. The client will perform personal hygiene with no prompting. Improved self-care is beneficial but is not the primary priority in suicide prevention.

C. The client will attend group by day 2. Participation in therapy is helpful, but ensuring physical safety takes precedence.

D. The client will remain free from injury for the duration of their hospitalization. The most critical goal for a client at risk for suicide is preventing self-harm, making this the priority outcome.

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Correct Answer is C

Explanation

A. Circulating nurse: The circulating nurse ensures that the time-out occurs but does not mark the surgical site.

B. Patient's primary nurse: The primary nurse is responsible for preoperative care but does not mark the site.

C. Surgeon: The surgeon performing the procedure is responsible for marking the surgical site to ensure accuracy and prevent wrong-site surgery.

D. Surgical technician: Surgical technicians assist with instruments and procedures but do not mark the surgical site.

A. Discontinue suctioning and administer 100% oxygen B. Discontinue suctioning and prepare for resuscitation C. Continue suctioning and administer 50% oxygen D. Continue suctioning and administer prescribed epinephrine

Correct Answer is A

Explanation

A. Discontinue suctioning and administer 100% oxygen: A drop in oxygen saturation and bradycardia indicates the patient is not tolerating suctioning. The priority is to stop suctioning and administer 100% oxygen to prevent hypoxia.

B. Discontinue suctioning and prepare for resuscitation: While severe cases may require resuscitation, the immediate intervention is oxygen administration, not premature resuscitation efforts.

C. Continue suctioning and administer 50% oxygen: Continuing suctioning may worsen hypoxia and bradycardia. Administering 50% oxygen may not be sufficient in a critical situation.

D. Continue suctioning and administer prescribed epinephrine: Epinephrine is used for anaphylaxis and severe cardiac issues, not for managing suction-related hypoxia.

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A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the time-out for a surgical procedure, who is responsible for marking the surgical site?

Correct Answer is C

Explanation

The nurse performs in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?

Correct Answer is A

Explanation

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?

When assessing a patient taking stimulant medications, the nurse should monitor for which of the following?

A school nurse is planning a presentation about identifying potential warning signs of suicide for high school students. Which of the following examples of behaviors should the nurse include in the teaching?

The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?

A nurse is caring for a client who has chronic respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect with this client?

The nurse would recognize which acronym as representing problem-oriented charting?

Which of the following statements are true

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?