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 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.

A. Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. B. Remain with this client and monitor the vital signs while the nurse takes the call. C. Tell the healthcare provider the nurse will return the phone call as soon as possible. D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.

Correct Answer is C

Explanation

Choice A rationale: Asking the healthcare provider to remain on "hold" may cause a delay in addressing the prescription and may not be the most efficient way to handle the situation.

Choice B rationale: Remaining with the client and monitoring vital signs is important, but it may not be necessary for the nurse to take the call personally.

Choice C rationale: Informing the healthcare provider that the nurse will return the phone call as soon as possible is a reasonable and appropriate response to address the prescription in a timely manner.

Choice D rationale: Writing down and repeating back the prescription is a good practice, but it may not address the urgency of the situation and the need for prompt communication with the healthcare provider.

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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

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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