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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.
Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.
Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica
Correct Answer is D
Explanation
Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.
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