While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

Determine who is assigned the care of the client.

Enter the room and quietly observe the interaction.

Notify the hospital security department immediately.

Instruct the visitor to leave the room immediately.

Answer and Explanation

The Correct Answer is D

Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.

Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.

Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.

Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.

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Correct Answer is C

Explanation

Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.

Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.

Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.

Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.

A. Apply portable oxygen for transport to radiology. B. Administer a nebulizer breathing treatment. C. Evaluate breathing pattern. D. Start the prescribed antibiotic.

Correct Answer is B

Explanation

Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.

Choice B rationale:The nebulizer treatment should be administered FIRST to alleviate the clients obstructed airway (respiratory distress)

Choice C rationale: Evaluating the breathing pattern is important but should be done immediately after implementing physician orders

Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.

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While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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