A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Determine if the client has a support system.

Schedule a mental health consult for the client.

Provide the client with information about coping strategies.

Encourage the client to attend a support group.

Answer and Explanation

The Correct Answer is A

A)   Determine if the client has a support system. - Assessing the client's current support network is essential to determine available resources and potential interventions.
B)   Schedule a mental health consult for the client. - While mental health support may be necessary, understanding the client's existing support system is the first step.
C)   Provide the client with information about coping strategies. - Providing coping strategies is important but should come after assessing the client's support system.

D)   Encourage the client to attend a support group. - Encouraging attendance at support groups can be helpful, but it's important to assess the client's current support system first.

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Correct Answer is C

Explanation

A) "I will rinse the contaminants from a bedpan with hot water." - While rinsing with hot water can help clean a bedpan, it does not effectively disinfect it.

B) "I will wear sterile gloves when bathing a client who is incontinent." - Sterile gloves are not necessary for routine bathing tasks; clean, non-sterile gloves are appropriate.
C) "I will use disinfectant to clean the blood pressure cuff after use on a client." - This statement indicates an understanding of the importance of disinfection to prevent the spread of infection.
D) "I will double-bag a client's linens each day." - Double-bagging linens may be unnecessary and does not directly address infection control principles.

A. Recheck the client's SaO2 level after having the client cough and clear their throat. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Check the client's medical records to see which medications were recently admitted.

Correct Answer is A

Explanation

A) Recheck the client's SaO2 level after having the client cough and clear their throat.

- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.

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A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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