The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Commend the client for her patience after a long wait in the admission process.

Determine the client's decision about homologous blood transfusion.

Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery.

Obtain primary source of information from the head of the spiritual group.

Answer and Explanation

The Correct Answer is B

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

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Correct Answer is A

Explanation

A. Notify information services department of the situation is the correct first step. The nurse should immediately report the issue to the information services department to resolve the problem with the computer system. This ensures that the issue is addressed promptly and minimizes any delays in documentation or patient care.

B. Wait for notification that the system has been rebooted is not the best action. While waiting for the system to reboot might be necessary, the nurse should first notify the information services department to expedite the resolution of the issue.

C. Identify information as late entry in the record may be necessary once the system is restored, but the immediate priority is to report the system failure so that it can be addressed and the documentation can be completed correctly.

D. Print electronic medical record (EMR) from backup server may be an option if the system cannot be restored, but the first step should be to notify the information services department. The backup server can be used if needed after the issue is reported.

A. Gives the client a hug and says, "It is okay to cry when you are sad." B. While touching the client's forearm, asks, "Would you like to talk about it?" C. "This is a bad time. I can see you are upset. I can come back later." D. "I am sorry to disturb you at a difficult time. This can wait until later."

Correct Answer is B

Explanation

A. Gives the client a hug and says, "It is okay to cry when you are sad" may seem comforting but could invade the client’s personal space and may not be appropriate in a professional setting without the client’s consent.

B. While touching the client's forearm, asks, "Would you like to talk about it?" is correct because it shows empathy, provides emotional support, and invites the client to share their feelings. The light touch conveys care without being intrusive.

C. "This is a bad time. I can see you are upset. I can come back later" dismisses the client’s emotional needs and prioritizes the nurse’s schedule over the client’s well-being.

D. "I am sorry to disturb you at a difficult time. This can wait until later" acknowledges the client’s emotions but does not provide immediate support or address their needs effectively.

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The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Nursing Test Bank

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