A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

State expectations for the client's behavior.

Request security personnel restrain the client.

Place the client in seclusion.

Debrief staff members about the conflict.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation 1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.

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Correct Answer is D

Explanation

a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.

b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.

c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.

d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.

A. "I will increase the flow rate if I feel short of breath." B. "I will check my oxygen equipment at least once daily." C. "I can use isopropyl alcohol to clean the nasal cannula when necessary." D. "I can use synthetic blankets on my bed."

Correct Answer is B

Explanation

This statement shows that the client understands the importance of regularly checking the oxygen equipment for proper functioning and potential issues. Regular equipment checks help ensure the client's safety and effective oxygen therapy.

Adjusting the oxygen flow rate should be done based on the healthcare provider's instructions and not solely based on subjective feelings. The client should follow the prescribed flow rate and consult their healthcare provider if experiencing increased shortness of breath.

Isopropyl alcohol is not recommended for cleaning the nasal cannula as it can cause drying and irritation. The client should use mild soap and water for cleaning the nasal cannula as per the healthcare provider's instructions.

Synthetic blankets can generate static electricity, which could be a fire hazard in the presence of oxygen. The client should be advised to use cotton or wool blankets, which are non-flammable and safer with oxygen therapy.

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A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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