A gravida 2 para 1 (G2P1) at 38-weeks gestation who is scheduled for a repeat cesarean section in one week is brought to the labor and delivery unit experiencing contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, "I've had 8 children and I know she is in labor.I want her to have her cesarean section right now!" Which action should the nurse take?

Request that the mother leave the room.

Notify the charge nurse of the situation.

Request security to remove her from the room.

Tell the mother to stop speaking for the client.

Answer and Explanation

The Correct Answer is A

A. Request that the mother leave the room: The nurse should prioritize the patient’s needs and comfort, the nurse should calmly request that she leave the room. This allows the nurse to focus on the client’s condition without interference and ensures that the client’s autonomy and wishes are respected.

B. Notify the charge nurse of the situation: While notifying the charge nurse may be appropriate if the situation escalates, the nurse should first try to address the issue directly by requesting that the mother leave the room.

C. Request security to remove her from the room:Security should be a last resort. The situation can likely be handled by the nurse in a calm, respectful manner without the need for security intervention, unless the behavior becomes aggressive or threatening.

D. Tell the mother to stop speaking for the client: This could be perceived as confrontational and disrespectful. It is more effective for the nurse to address the mother’s disruptive behavior by requesting she leave the room so that the client’s privacy and autonomy can be maintained.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","E","F"]

Explanation

A. Check the temperature of the humidified oxygen attached to the ventilator: The client is intubated and receiving humidified oxygen. If the oxygen is cold, it can contribute to hypothermia. Ensuring that the humidified oxygen is at an appropriate temperature will help prevent further heat loss.

B. Instill warm fluids in the nasogastric tube: Instilling warm fluids via a nasogastric tube is not a standard or efficient method for core rewarming in a hypothermic trauma client. It introduces a risk of aspiration and is less effective than other core rewarming techniques.

C. Microwave a pack of gauze and distribute across the body: Microwaving a pack of gauze is not a safe or controlled method to warm the body. It could result in burns or uneven heat distribution, which could be harmful.

D. Place ice packs around the client's head: Ice packs are typically used to lower body temperature, not raise it. Applying ice packs would worsen the hypothermia and is inappropriate in this case.

E. Apply warm blankets: Warm blankets are a common and effective method to increase body temperature in hypothermic patients. This will help promote heat retention and stabilize the patient's body temperature.

F. Use a fluid warmer for intravenous fluids: Cold intravenous fluids can lower body temperature further. A fluid warmer ensures that fluids are administered at body temperature, helping to prevent hypothermia.

G. Administer intravenous fluids with a rapid infuser: While rapid fluid administration is important for hemodynamic stabilization in trauma patients, it does not directly address body temperature. Without a warmer, rapid infusers can contribute to further cooling.

H. Administer an antipyretic: Antipyretics are used to reduce fever, but there is no indication that the client has a fever. The concern here is hypothermia, not an elevated temperature, so antipyretics would not be appropriate in this situation.

A. Request a spiritual advisor's consult. B. Encourage viewing of the body to accept the death. C. Provide support of the spouse's feelings. D. Ask the relatives about how the spouse is coping.

Correct Answer is C

Explanation

A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.

B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.

C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.

D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Correct Answer is C

Explanation

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?