A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Discuss with the client his inappropriate behavior prior to seclusion.

Offer fluids every 2 hr.

Document the client’s behavior prior to being placed in seclusion.

Assess the client’s behavior once every hour.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.

Choice A rationale:

Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.

Choice B rationale:

Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.

Choice C rationale:

Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.

Choice D rationale:

Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.

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Correct Answer is C

Explanation

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage. Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage. Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage. Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults. Normal ranges for plasma clotting variables depend on the specific test and method used.

A. Schedule nursing staff training for infection control procedures. B. Meet with providers to discuss measures to decrease the infections. C. Revise the current policy for catheter care. D. Identify possible precipitating factors related to the infections.

Correct Answer is D

Explanation

The correct answer is choice **D. Identify possible precipitating factors related to the infections**.

Choice D rationale:

As a charge nurse concerned about a recent increase in facility-acquired catheter infections, the first step should be to identify possible precipitating factors related to the infections. This involves conducting a thorough investigation to determine the root causes of the increased infection rates. By identifying the underlying factors, the nurse can then develop targeted interventions to address the specific issues and prevent further infections.

Choice A rationale:

While scheduling nursing staff training for infection control procedures is important, it should not be the first action taken. Before implementing training, it is crucial to identify the factors contributing to the increased infection rates to ensure that the training addresses the specific issues at hand.

Choice B rationale:

Meeting with providers to discuss measures to decrease the infections is a necessary step, but it should not be the first action. Providers need to be informed about the situation, but their input will be more valuable once the precipitating factors have been identified.

Choice C rationale:

Revising the current policy for catheter care may be necessary, but it should not be the first action. Policies should be based on evidence-based practices and tailored to address the specific issues identified through the investigation.

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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings is an indication that the medication has been effective

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?