A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first?

Document the client's mood and affect.

Search the client's personal belongings.

Attend an interdisciplinary team meeting.

Assign the client to a semi-private room.

Answer and Explanation

The Correct Answer is B

A. Document the client’s mood and affect.
Important, but not the first action.

B. Search the client’s personal belongings.
Safety comes first. The priority is removing any items that could be used for self-harm.

C. Attend an interdisciplinary team meeting.
Will occur later-client’s immediate safety takes priority.

D. Assign the client to a semi-private room.
Private rooms are preferred to allow better monitoring and safety checks.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Wear clean gloves when cleansing the tracheostomy site.
Sterile gloves are required in the immediate post-op period to prevent infection.

B. Cleanse the tracheostomy site with 0.9% sodium chloride.
Isotonic saline is used for routine tracheostomy site cleansing to reduce infection risk.

C. Change the client's tracheostomy ties every 72 hr.
Ties should be changed as needed or per protocol, often more frequently in early post-op period.

D. Suction the client's tracheostomy every 6 hr.
Suction as needed, not on a fixed schedule, to avoid mucosal trauma.

A. Has a vocabulary of four words B. Jumps with both feet C. Weighs 12 kg (26.5 lb) D. Can draw a circle

Correct Answer is A

Explanation

A. Has a vocabulary of four words:
By 24 months, toddlers should say at least 50 words and begin combining two words. A vocabulary of only four words is delayed speech development.

B. Jumps with both feet:
This is a normal gross motor milestone for a 2-year-old.

C. Weighs 12 kg (26.5 lb):
This is within the normal weight range for a 24-month-old.

D. Can draw a circle:
Some 2-year-olds may begin to imitate circular strokes, so this is not a concern.

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A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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