A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith." The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?
Ask Mrs. Smith where her husband is right now.
Explain that the chart must contain an error.
Apologize and declare confusion about the client.
Ask the client about preferred forms of address.
The Correct Answer is D
A. Assuming the client is someone else's spouse based on a name may be inappropriate and could lead to misunderstanding.
B. The chart may not necessarily contain an error, and jumping to conclusions could be unprofessional.
C. Apologizing and declaring confusion may make the client uncomfortable. It's more respectful to inquire directly.
D. Asking the client about their preferred form of address is the most respectful and professional approach.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.
B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.
C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.
D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.
Correct Answer is B
Explanation
A. Bleeding precautions are not required as the issue pertains to neutropenia, not thrombocytopenia.
B. Placing the client in a private room is appropriate as the ANC calculation (WBC × [% neutrophils]) indicates severe neutropenia, increasing the risk of infection.
C. Simply documenting findings does not address the client’s increased infection risk.
D. Blood cultures and antibiotics may be needed later but require additional signs of infection to proceed.
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