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.

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 C

Explanation

A. After each instruction, ask if the client understands is not the most reliable method because the client may answer affirmatively out of politeness or lack of comprehension.

B. Provide written instructions in the client's native language is helpful as a supplementary teaching tool but does not evaluate the client's understanding or ability to perform wound care.

C. Have the client demonstrate prescribed wound care is the most effective method because it allows the nurse to directly observe the client’s technique and understanding, ensuring they can perform the task correctly at home.

D. Have an interpreter repeat the wound care instructions ensures accurate communication but does not assess whether the client can perform the care independently.

A. Determine when each client last received pain medication. B. Evaluate both clients' pain using a standardized pain scale. C. Provide nonpharmacologic pain management interventions. D. Prepare both clients' medication and take to them at once.

Correct Answer is B

Explanation

A. Determine when each client last received pain medication is an important step in managing pain, but it does not address the immediate need to evaluate the severity of the clients' pain. Knowing when they last received pain medication can help with medication timing but should follow a thorough assessment.

B. Evaluate both clients' pain using a standardized pain scale is the most appropriate first action. This allows the nurse to assess the severity of each client’s pain and prioritize which client requires more immediate attention. Pain severity, rather than timing of medication, should guide the nurse's intervention.

C. Provide nonpharmacologic pain management interventions can be helpful, but it does not address the immediate need for assessing and addressing the severity of pain. Nonpharmacologic interventions can be used as an adjunct but should not replace proper assessment and pharmacologic management if necessary.

D. Prepare both clients' medication and take to them at once could lead to a delay in addressing the most severe pain. It is important to assess pain levels first to prioritize care, as one client may require medication sooner than the other.

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

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

Naxlex Comprehensive Predictor Exams

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is C

Explanation

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Correct Answer is B

Explanation

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

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

To assess the quality of an adult client's pain, which approach should the nurse use?

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)