A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are
_
and
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Place the client in a private room (Option 1): Given the positive test results for tuberculosis (TB) exposure, placing the client in a private room is crucial for infection control. This helps prevent the spread of TB, which is a highly contagious disease, to other patients and healthcare staff. Isolation is a standard precaution for patients suspected of having active TB.

Apply supplemental oxygen (Option 2): The client's oxygen saturation is low at 88% on room air, indicating hypoxemia. Administering supplemental oxygen is essential to improve the patient's oxygen levels, ensure adequate tissue perfusion, and address any respiratory distress the patient may be experiencing.

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Correct Answer is B

Explanation

A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.

B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.

C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.

D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.

A. Ask the client to explain her feelings. B. Request that someone from the client's family participate in the care. C. Explain why her participation is important. D. Tell the client that it is safe to touch her ostomy.

Correct Answer is A

Explanation

A. Asking the client to explain her feelings shows empathy and encourages open communication. It allows the nurse to understand the client's concerns and address them appropriately.

B. Requesting family participation may be helpful, but it does not address the client’s specific feelings of reluctance.

C. While explaining the importance of participation can be beneficial, it may not address the client's emotional response or specific concerns.

D. Simply telling the client it is safe to touch her ostomy does not address her reluctance or provide emotional support.

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A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. The first two actions the nurse should take are ___ and ___

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?

A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?

A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?

A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?

A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are
_
and
_