An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?

Discuss with the family about placing the client in a skilled care facility.

Determine if the client is manifesting other neurologic changes.

Request family members report when the client is left alone.

Apply a restraining device to prevent the client from self injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.

Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.

Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.

A. Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. B. Remain with this client and monitor the vital signs while the nurse takes the call. C. Tell the healthcare provider the nurse will return the phone call as soon as possible. D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.

Correct Answer is C

Explanation

Choice A rationale: Asking the healthcare provider to remain on "hold" may cause a delay in addressing the prescription and may not be the most efficient way to handle the situation.

Choice B rationale: Remaining with the client and monitoring vital signs is important, but it may not be necessary for the nurse to take the call personally.

Choice C rationale: Informing the healthcare provider that the nurse will return the phone call as soon as possible is a reasonable and appropriate response to address the prescription in a timely manner.

Choice D rationale: Writing down and repeating back the prescription is a good practice, but it may not address the urgency of the situation and the need for prompt communication with the healthcare provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

The nurse manager is encouraging the hospital nursing administrators to seek Magnet status for an acute care hospital. Which rationale should the nurse use to describe the greatest advantage of obtaining Magnet status?

During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?