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. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

A. Clean the urinary meatus before retracting the foreskin. B. Position the sterile field even with the nurse's hips. C. Use a swab to wipe the meatus in back-and-forth motions. D. Advance the catheter before inflating the balloon.

Correct Answer is A

Explanation

A. Clean the urinary meatus before retracting the foreskin is the correct action. Before retracting the foreskin, the nurse should clean the meatus to prevent contamination of the catheterization site. This ensures that any bacteria present are removed before inserting the catheter.

B. Position the sterile field even with the nurse's hips is not directly related to the procedure for an uncircumcised male client. The sterile field should be positioned at a level where the nurse can comfortably reach it without contaminating it, but this does not specifically address the care of an uncircumcised male.

C. Use a swab to wipe the meatus in back-and-forth motions is incorrect. The meatus should be cleaned using a circular motion, starting at the meatus and working outward. Back-and-forth motions could cause contamination of the area.

D. Advance the catheter before inflating the balloon is an appropriate action during catheter insertion; however, this is not specific to the care of an uncircumcised male client. The balloon should be inflated only after the catheter is fully inserted and urine flow is confirmed.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Correct Answer is A

Explanation

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