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 C
Explanation
Choice A rationale: The initial administration of the opioid analgesic is appropriate as long as the nurse adheres to the prescription made.
Choice B rationale: Administering naloxone via IV is an appropriate intervention to reverse the effects of opioid toxicity. It is not the focus of counseling in this scenario.
Choice C rationale: The nurse should have notified the healthcare provider as soon as the client's respiratory rate decreased to 6 breaths/minute, which is a sign of respiratory depression caused by the opioid analgesic. The nurse should not have waited until the client's respiratory rate decreased to 4 breaths/minute, which is a life-threatening condition that requires immediate intervention.
Choice D rationale: Documentation of the client's respiratory rate is essential for monitoring, and there is no indication that the documentation was inappropriate.
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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