A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?
Notify the nurse manager.
Check the family member's vital signs.
Obtain the family member's health history.
Complete an incident report.
The Correct Answer is B
A) Notify the nurse manager:
While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.
B) Check the family member's vital signs:
The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.
C) Obtain the family member's health history:
Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.
D) Complete an incident report:
Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "I respect your right to choose to discontinue treatment."
While this statement acknowledges the client's autonomy and right to make decisions about their care, it does not directly address the nurse's commitment to honesty or transparency in discussing hospice care.
B) "I will have a hospice nurse come discuss this kind of care with you."
While involving a hospice nurse is a supportive action, it does not directly demonstrate the nurse's commitment to honesty or openness in discussing hospice care with the client.
C) "I will answer any questions you have about hospice care honestly."
This statement demonstrates veracity by explicitly stating the nurse's commitment to providing truthful and accurate information about hospice care. It reassures the client that they can trust the nurse to provide honest answers to their questions.
D) "I work with hospice services to help you transition to their care."
While this statement indicates the nurse's involvement in facilitating the transition to hospice care, it does not specifically address the nurse's commitment to honesty or truthfulness in discussing hospice care with the client.
Correct Answer is A
Explanation
A. Verify the medication name along with its intended purpose.
Rationale:
Verifying the medication name along with its intended purpose is crucial to ensure accuracy and patient safety. In this scenario, the nurse should confirm that the medication name "propranolol" matches the intended medication prescribed by the provider. Additionally, understanding the purpose of the medication ensures that the nurse can correctly communicate this information to the patient, reinforcing patient education and adherence to the prescribed treatment plan. Verifying the medication name and purpose helps prevent medication errors and promotes safe medication administration practices.
B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."
Verbalizing the letters "B-I-D" for the dosing frequency instead of saying "twice per day" is not the most appropriate action in this situation. While using medical abbreviations like "B-I-D" (which stands for "bis in die" or "twice a day") is common in healthcare settings, it's essential to ensure clear communication with all involved parties, including patients and providers. Using layman's terms like "twice per day" helps avoid confusion and promotes better understanding, reducing the risk of medication errors due to misinterpretation.
C. Transcribe the medication name using the trade name.
Transcribing the medication name using the trade name is not appropriate unless specifically instructed by the provider or if there is a specific reason to do so. In this scenario, the nurse should use the generic name "propranolol" when transcribing the medication to ensure consistency and accuracy in documentation and communication. Using trade names can lead to confusion, especially in environments where multiple brand names may exist for the same generic medication.
D. Remind the provider to countersign the prescription in 72 hr.
Reminding the provider to countersign the prescription in 72 hours is not relevant to the immediate task of verifying and reading back the prescription information. While ensuring proper documentation and authorization of prescriptions is important, it should not be addressed during the initial verification and communication process. This action can be addressed separately, following the completion of the prescription verification process.
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