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 B

Explanation

A. Tie the knot with a double turn or square knot: While using a secure knot is important, the most critical factor is that the knot can be easily and quickly released in an emergency. A half bow knot may be inadequate for rapid release, but the primary focus should be ensuring quick accessibility.

B. Ensure that the knot can be quickly released: This is the most important action to ensure the safety of the client. In the event of an emergency, such as difficulty breathing or a need to quickly remove restraints, the knot must be easily undone without delay.

C. Move the ties so the restraints are secured to the side rails: Tying restraints to side rails is inappropriate because the side rails can move, which may result in injury. Restraints should be attached to a stationary part of the bed frame.

D. Ensure that the restraints are snug against the client's wrists: While restraints should be applied snugly to prevent injury, they should not be too tight. The primary concern here is ensuring that the restraints are safely and quickly releasable, not just snug.

A. The client reports he was able to sleep through the night B. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. C. The client reports mild nausea and has no desire to eat breakfast D. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage E. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric

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

Explanation

Rationale for Correct Choices:

The nurse assesses the client. The client reports he was able to sleep through the night:
Being able to sleep through the night suggests that the client’s pain is adequately managed, indicating progress in terms of pain control post-surgery or trauma care.
The left arm is warm to touch: The warmth of the left arm indicates that circulation has improved from initially cool to touch. This is a positive sign, as it suggests that there are no significant vascular complications following the fracture or trauma.
The client's left shoulder and collarbone are symmetric: Symmetry of the shoulder and collarbone suggests that there is no new displacement or injury to the bones post-trauma or surgery. This is a good sign indicating that the fracture is properly stabilized.

Rationale for Incorrect Choices:

The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers: The numbness, tingling, and inability to move his fingers may indicate nerve involvement, which could be a sign of complications such as nerve compression or injury due to the fracture.
The client reports mild nausea and has no desire to eat breakfast: Mild nausea is expected after anesthesia or pain medications, but continued lack of appetite or worsening nausea may signal complications, such as a delayed reaction to anesthesia or a side effect from medication, which should be monitored.
There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage: While some blood may be expected post-surgery or after trauma, a blood stain of this size should be evaluated for any indication of active bleeding or complications such as hematoma formation. It may not be expected if the bleeding had been controlled.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is B

Explanation

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

Explanation

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?

Exhibits The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.

A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

When should intimate partner violence (IPV) screening occur?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?