A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?
Clarify the source of the referral
Contact the family by phone
Implement the nursing process.
Schedule a time for the home visit
The Correct Answer is A
Rationale:
A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.
B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.
C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.
D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Insert a large-bore IV catheter: A large-bore (18–20 gauge) IV catheter is required to allow rapid infusion of blood products if needed, minimizing hemolysis and ensuring adequate flow. This is critical for the safety and effectiveness of the transfusion, especially in clients who may be hemodynamically unstable.
B. Witness the client signing a consent for transfusion: Obtaining informed consent ensures the client understands the risks, benefits, and alternatives to the blood transfusion. Witnessing the signature is a legal and ethical requirement to confirm that the client has voluntarily agreed to the procedure.
C. Have a second nurse confirm the information on the blood label: Verification by a second nurse prevents administration errors, such as giving the wrong blood type or unit. This double-check process is essential for patient safety and is standard protocol before starting a transfusion.
D. Flush the transfusion tubing with dextrose 5 in water: Blood products should not be administered through tubing flushed with dextrose solutions because dextrose can cause red blood cell hemolysis. Normal saline is the only appropriate solution for priming and flushing blood administration tubing.
E. Explain to the client that transfusion reactions are not serious: Transfusion reactions can be life-threatening, including hemolytic, allergic, or febrile reactions. Minimizing the seriousness of these risks is inappropriate; the client should be informed about potential complications and instructed to report any symptoms immediately.
Correct Answer is C
Explanation
Rationale:
A. "I will provide my child with high-fiber foods": While fiber is important for overall health, many high-fiber grains contain gluten, which must be avoided in celiac disease. Offering high-fiber foods without confirming they are gluten-free could cause intestinal damage and symptoms in the child.
B. "I will give my child whole wheat toast and milk for breakfast": Whole wheat contains gluten, which triggers an autoimmune response in children with celiac disease. Serving whole wheat toast is unsafe and indicates a misunderstanding of dietary restrictions for managing this condition.
C. "I will keep my child on a gluten-free diet": A strict gluten-free diet is the primary treatment for celiac disease. Eliminating all sources of wheat, barley, rye, and derivatives allows intestinal healing, prevents symptoms, and reduces the risk of long-term complications, showing correct understanding of dietary management.
D. "I will administer digestive enzymes with meals and snacks.": Digestive enzymes are not a standard treatment for celiac disease and do not prevent the autoimmune response caused by gluten. The focus should remain on dietary avoidance of gluten rather than relying on enzyme supplementation.
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