A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

Notify the nurse manager.

Check the family member's vital signs.

Obtain the family member's health history.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

A) Notify the nurse manager:

While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.

B) Check the family member's vital signs:

The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.

C) Obtain the family member's health history:

Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.

D) Complete an incident report:

Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.

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Correct Answer is C

Explanation

A) "I will attempt to extinguish the fire before calling the fire department.": This statement indicates a misunderstanding of fire safety principles. It's crucial for individuals to prioritize their safety and evacuate the premises immediately in the event of a fire. Attempting to extinguish the fire before calling the fire department can waste valuable time and put the individual at risk.

B) "I should change the batteries in my smoke alarms every 2 years.": While changing smoke alarm batteries regularly is essential for ensuring they function properly, the recommended interval for battery replacement is typically every 6 months, not every 2 years. This statement reflects a misunderstanding of the recommended maintenance schedule for smoke alarms.

C) “I should spray the extinguisher from side to side on the fire.": This statement demonstrates an understanding of proper fire extinguisher use. When using a fire extinguisher, it's essential to aim the extinguisher nozzle at the base of the fire and sweep it from side to side until the fire is extinguished. This technique helps to smother the flames effectively and prevent re-ignition.

A. "Why have you decided not to have the procedure?" B. "Don't worry. You will adjust to the colostomy quickly." C. "It sounds like you have concerns about the procedure." D. "Do you think that's the right decision for you and your family?"

Correct Answer is C

Explanation

Answer: C

Rationale:

C) "It sounds like you have concerns about the procedure."
This response is therapeutic and encourages the client to express their concerns, allowing the nurse to understand the client's feelings without judgment. It opens up a supportive dialogue where the client can discuss their fears, anxieties, or misconceptions about the colostomy, which can then be addressed appropriately.

A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.

B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.

D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.

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A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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