While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.
What is the most appropriate action for the nurse to take?
Reassure the client that the nurse will return after all vital signs are taken.
Pull up a chair and sit beside the client’s bed.
Allow the client to hold the nurse’s hand until the vital signs can be completed.
Tell the client that he must release the nurse’s hand.
The Correct Answer is B
Choice A rationale
Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.
Choice B rationale
Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.
Choice C rationale
Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.
Choice D rationale
Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.
Choice B rationale
Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.
Choice C rationale
Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.
Choice D rationale
Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.
Correct Answer is C
Explanation
Choice A rationale
There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.
Choice B rationale
Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.
Choice C rationale
Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.
Choice D rationale
Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.
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