A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?
Offer reassurance that she is not alone.
Explain that alternative treatment options may be helpful.
Encourage the wife to share her feelings.
Remind her that her husband may still live a long time.
The Correct Answer is C
Choice A reason: Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.
Choice B reason: Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.
Choice C reason: Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.
Choice D reason: Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.
Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.
Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.
Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.
Correct Answer is D
Explanation
Choice A reason: Giving positive feedback to the PN and documenting the skill competency is not the appropriate action to take. The PN did not demonstrate proper sterile technique, as he touched the outside of the sterile glove package and the sterile sponges with his bare hands, contaminating them.
Choice B reason: Explaining to the PN that the sterile sponges are not needed for the procedure is not the relevant action to take. The PN may have been following the instructions of the healthcare provider, who may have requested the sponges for the procedure. The issue is not the need for the sponges, but the way the PN handled them.
Choice C reason: Reminding the PN to wash his hands before applying the sterile gloves is not the sufficient action to take. Washing the hands is an important step in maintaining infection control, but it does not correct the mistake the PN made by touching the sterile items with his bare hands.
Choice D reason: Asking the PN to remove the gloves and sponges and start over with a new set is the best action to take. It ensures that the PN follows the correct sterile technique and does not compromise the safety of the client or the procedure. It also provides an opportunity for the charge nurse to teach the PN how to avoid contamination.
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