A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?

Serve meals with plastic utensils.

Assign another client to accompany the client to therapy sessions

Assign the client to a private room

Check on the client every 4 hr

Answer and Explanation

The Correct Answer is A

Answer: A

Rationale:

A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.

B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.

C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.

D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.

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Correct Answer is D

Explanation

Answer: (D) Refrigerate the specimen until the time of transport to the laboratory

Rationale:

A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.

A. "You should verify the identity of anyone who wants to remove your baby from the room." B. "You can leave your baby in your room while you walk in the hallway." C. "Your baby should have one identification band on either their right arm or right leg." D. "You can leave the unit with your baby as long as you notify the nurse."

Correct Answer is A

Explanation

The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.

Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.

Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.

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A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the parent of an infant who is receiving furosemide. The nurse should reinforce with the parent that which of the following laboratory tests will be monitored while the infant is receiving this medication?

A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following client statements indicates an understanding of the teaching?

A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse recommend considering when administering medication?

A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open- angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions?

A nurse is reviewing the medical record of a client who is requesting an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptives?