A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Ensure the client swallows each dose of medication.

Limit the personal toiletries in the client's room to cologne.

Observe the client's behavior every 2 hr.

Keep the client's door shut when they are in the room.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.

B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.

C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.

D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.

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Correct Answer is A

Explanation

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface. C. Apply sterile gloves. D. Open the outermost flap of the sterile kit away from the nurse's body.

Correct Answer is D

Explanation

Rationale:

A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: This step comes later in the process of opening a sterile field. Side flaps should be opened after the top (farthest) flap to prevent reaching over the sterile field and contaminating it.

B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the closest flap first risks contaminating the sterile field by reaching over it. This flap should be opened last, after the top and side flaps are already secured.

C. Apply sterile gloves: Sterile gloves are applied after the sterile field is prepared and all supplies are organized within the sterile area. Putting them on too early may lead to contamination during field setup.

D. Open the outermost flap of the sterile kit away from the nurse's body: The first step in establishing a sterile field is to open the flap away from the body. This minimizes contamination by preventing the nurse from leaning over the sterile surface.

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A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

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