A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Let each family member ask a question one at a time.

Request the healthcare provider to speak with the family.

Ask the family to identify a specific spokesperson.

Page a chaplain on call to be present for questions.

Answer and Explanation

The Correct Answer is C

A) This intervention is not the best because it may take too much time and energy from the nurse, who needs to focus on the client's critical condition. The nurse may also have to repeat the same information multiple times, which can be frustrating and confusing for both the nurse and the family.

B) This intervention is not the best because it may not be feasible or appropriate at this time. The healthcare provider may be busy with other clients or procedures, and may not be able to speak with the family right away. The healthcare provider may also need to obtain the client's consent or permission before disclosing any information to the family, which may not be possible if the client is sedated.

C) This intervention is the best because it can help reduce the number and frequency of questions, and facilitate clear and consistent communication between the nurse and the family. The nurse can ask the family to choose one person who will act as their representative and spokesperson, and who will relay any information or updates to the rest of the family. This can also help respect the client's privacy and confidentiality, and prevent any conflicting or contradictory messages.

D) This intervention is not the best because it may not address the family's informational needs or preferences. The chaplain on call may provide spiritual or emotional support to the family, but may not be able to answer any medical or technical questions. The family may also have different religious or cultural beliefs that may not align with the chaplain's role or perspective.

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Correct Answer is B

Explanation

Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.

Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.

Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.

Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.

A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit. B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension. C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank. D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.

Correct Answer is D

Explanation

Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.

Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.

Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.

Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.

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A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

Correct Answer is B

Explanation

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

Correct Answer is D

Explanation

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?

A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)