A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
Let each family member ask a question one at a time.
Request the healthcare provider to speak with the family.
Ask the family to identify a specific spokesperson.
Page a chaplain on call to be present for questions.
The Correct Answer is C
A) This intervention is not the best because it may take too much time and energy from the nurse, who needs to focus on the client's critical condition. The nurse may also have to repeat the same information multiple times, which can be frustrating and confusing for both the nurse and the family.
B) This intervention is not the best because it may not be feasible or appropriate at this time. The healthcare provider may be busy with other clients or procedures, and may not be able to speak with the family right away. The healthcare provider may also need to obtain the client's consent or permission before disclosing any information to the family, which may not be possible if the client is sedated.
C) This intervention is the best because it can help reduce the number and frequency of questions, and facilitate clear and consistent communication between the nurse and the family. The nurse can ask the family to choose one person who will act as their representative and spokesperson, and who will relay any information or updates to the rest of the family. This can also help respect the client's privacy and confidentiality, and prevent any conflicting or contradictory messages.
D) This intervention is not the best because it may not address the family's informational needs or preferences. The chaplain on call may provide spiritual or emotional support to the family, but may not be able to answer any medical or technical questions. The family may also have different religious or cultural beliefs that may not align with the chaplain's role or perspective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Instructing UAPs to transfer all non-ambulatory clients via wheelchairs is not a good intervention, as it may expose the clients and the UAPs to smoke and fire, and cause panic and congestion in the hallways. The charge nurse should follow the RACE protocol (Rescue, Alarm, Contain, Extinguish), which means rescuing only those clients who are in immediate danger, and containing the fire by closing doors and windows.
Choice B Reason:Following the RACE acronym, evacuation of those in immediate danger is the priority. Instructing ambulatory clients to move toward the nearest fire exit is the most efficient way to clear the unit. Nursing staff must guide these individuals to safety first to minimize congestion and allow for focused assistance.
department's efforts. The charge nurse should follow the RACE protocol, which means evacuating only as a last resort, and only after receiving instructions from the fire department.
Choice C Reason: Staying in rooms is a "defend in place" strategy, but it is inappropriate once an official evacuation order has been issued by the operator. Closing doors is vital to contain smoke and fire, but instructing everyone to remain stationary during an active evacuation order increases the risk of injury.
Choice D Reason: Announcing in a calm voice that all visitors should proceed immediately to the first floor via the service elevators is not a good intervention, as it may endanger the visitors and cause more damage. The charge nurse should follow the RACE protocol, which means alarming others by activating the fire alarm system and calling 911. The charge nurse should also instruct visitors not to use elevators during a fire, as they may malfunction or trap them inside.
Correct Answer is A
Explanation
Choice A Reason: The nurse's first responsibility is to assess the underlying cause of the refusal. Since fluid volume overload is a critical condition, understanding whether the refusal is due to pain, fatigue, or a lack of understanding allows the nurse to provide appropriate education or interventions to ensure compliance with the plan of care.
Choice B Reason:Instructing the UAP to use a bed scale ignores the client's right to refuse and fails to address the initial conflict. Forcing a weight measurement without assessment can damage the nurse-client relationship. The nurse must first determine if the client is physically unable to stand or simply unwilling to participate.
Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.
Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.
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