A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Medicate the client with alprazolam.

Reorient the client to his surroundings.

Measure the client's vital signs.

Offer reassurance to the family.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.

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Correct Answer is B

Explanation

Choice A Reason:
"I will have a nurse witness the signing of my living will." This statement is incorrect. While having a witness present during the signing of a living will is important for validity in some jurisdictions, the statement alone does not demonstrate an understanding of advance directives. It's essential to ensure that the client comprehends the purpose and content of the document, not just the procedural aspect.
Choice B Reason:
"I can make changes to my living will even after I sign it." This statement is correct. Understanding that living wills can be revised or updated as needed reflects comprehension of the flexibility and control that advance directives provide. It's crucial for clients to know that they can make changes to their directives if their preferences or circumstances change.
Choice C Reason:
"I should choose a family member as my health care proxy." This statement is incorrect. While selecting a family member as a health care proxy is a common choice, it may not necessarily indicate an understanding of advance directives. The key aspect is that the client understands the role of the health care proxy and chooses someone who can make decisions aligned with their wishes.
Choice D Reason:
"I need to have my attorney review my advance directives." This statement is incorrect. While it can be beneficial to have an attorney review advance directives for legal clarity and compliance with state laws, it is not a requirement for their validity. The statement alone does not demonstrate understanding of advance directives.

A. A client who is at 32 weeks of gestation and has premature rupture of membranes B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor C. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump D. A client who has gestational diabetes and is receiving biweekly nonstress tests

Correct Answer is C

Explanation

Choice A Reason:
A client who is at 32 weeks of gestation and has premature rupture of membranes is incorrect. This client is at risk for preterm labor and complications related to premature birth. Management involves monitoring for signs of labor, assessing fetal well-being, and potentially administering medications to prevent preterm labor. This requires obstetrical-specific knowledge and expertise.
Choice B Reason:
A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor is incorrect. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to organs, often the kidneys. Induction of labor in the setting of preeclampsia requires careful monitoring of maternal and fetal well-being, including blood pressure monitoring and fetal heart rate monitoring. Additionally, the use of misoprostol for induction requires understanding of its dosage, administration, and potential side effects, which are specific to obstetrical care.
Choice C Reason:
A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump is correct. This client is postoperative following a Cesarean section and is likely in need of pain management through a PCA pump. Postoperative care after a Cesarean section involves monitoring for signs of complications such as infection, bleeding, and wound healing, as well as managing pain effectively. While nurses with medical-surgical experience may be familiar with PCA pumps, the postoperative care of a cesarean section client involves obstetrical-specific considerations such as uterine monitoring, assessment of lochia (vaginal discharge after childbirth), and breastfeeding support.
Choice D Reason:
A client who has gestational diabetes and is receiving biweekly nonstress tests is incorrect. Gestational diabetes requires monitoring of maternal blood glucose levels and fetal well-being. Nonstress tests are a common method of assessing fetal well-being in pregnancies complicated by conditions such as gestational diabetes. Nurses caring for clients with gestational diabetes need to understand the management of blood glucose levels, dietary considerations, insulin administration if needed, and fetal monitoring techniques. This requires obstetrical-specific knowledge and expertise.

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A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

Correct Answer is C

Explanation

A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

A nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions by the newly licensed nurse should the nurse identify as an indication of effective time management?

A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?

A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice?

A nurse is teaching a newly licensed nurse about telephone prescriptions. Which of the following information should the nurse include?

A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event?

A nurse manager is discussing responsibilities of the nurse manager role with a group of newly licensed nurses. Which of the following responsibilities should the nurse include? (Select all that apply.)

A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?