A nurse is caring for a client who has recently undergone a total bilateral mastectomy.

Which of the following statements by the client requires immediate action by the nurse?

"I don't understand why everyone is so worried about me."

"I don't know if I'll ever find someone who wants to marry me."

"When I look at myself in the mirror, I don't know if I can go on."

"I feel like the doctor pressured me into having the mastectomy."

Answer and Explanation

The Correct Answer is C

A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.

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Correct Answer is ["C","D","F"]

Explanation

A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.

E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.

F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

A. Evacuate clients from the area. B. Pull the lever on the fire alarm box. C. Close the fire doors on the unit. D. Use a fire extinguisher to put out the fire.

Correct Answer is A, B, C, D

Explanation

Sequence of Actions:

A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire.

B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system.

C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire's progress and safeguarding other parts of the building.

D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.

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A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nurse is caring for a client following abdominal surgery. Exhibits Select the findings the nurse should report to the provider.

Correct Answer is ["C","D","F"]

Explanation

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A, B, C, D

Explanation

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A nurse is caring for a client who has recently undergone a total bilateral mastectomy.

Which of the following statements by the client requires immediate action by the nurse?