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. Call the pharmacy to see which medications should be taken indicates a misunderstanding of discharge instructions. The client should already have a clear understanding of their prescribed medications before discharge, including dosage, timing, and purpose. This responsibility lies with the healthcare provider or nurse, not the pharmacy, and the nurse should provide additional clarification.

B. Verify that a follow-up appointment has been scheduled is appropriate and demonstrates that the client understands the importance of follow-up care to monitor recovery and address any complications.

C. Notify the healthcare provider (HCP) if a fever develops is a correct action, as fever may indicate infection, a common postoperative complication that requires prompt attention.

D. Use movement techniques taught by the physical therapists reflects proper understanding of postoperative mobility instructions, which are crucial for preventing complications such as blood clots and for supporting recovery.

A. Assess the client for signs of diminished circulation in the hands. B. Proceed with teaching the client how to walk with the crutches. C. Ask the client to sit down while the crutch length is adjusted. D. Confer with the physical therapist for correct crutch size.

Correct Answer is B

Explanation

A. Assess the client for signs of diminished circulation in the hands is unnecessary at this stage, as the primary concern is ensuring proper crutch fit and teaching safe use.

B. Proceed with teaching the client how to walk with the crutches is correct because a space of three finger-widths between the crutch and the axilla indicates proper crutch height. This prevents nerve damage and discomfort in the axilla.

C. Ask the client to sit down while the crutch length is adjusted is not needed since the crutches are already appropriately adjusted based on the observed spacing.

D. Confer with the physical therapist for correct crutch size is unnecessary because the nurse can confirm that the crutches are properly fitted based on standard guidelines.

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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

Naxlex Comprehensive Predictor Exams

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is A

Explanation

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is B

Explanation

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