The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Commend the client for her patience after a long wait in the admission process.

Determine the client's decision about homologous blood transfusion.

Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery.

Obtain primary source of information from the head of the spiritual group.

Answer and Explanation

The Correct Answer is B

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Around the nostrils is a common area for skin damage when using a nasal cannula. The constant pressure and friction from the cannula tubing can cause irritation or breakdown around the nostrils.

B. Bridge of the nose is another area to assess for skin damage. The nasal cannula can cause pressure ulcers or redness on the bridge of the nose, especially if the cannula is not properly positioned or if the client wears it for prolonged periods.

C. Across the forehead is not typically an area affected by a nasal cannula. The cannula does not usually make contact with the forehead, so skin damage in this area is unlikely.

D. Over the cheeks is an important area to assess. The tubing of the nasal cannula can rub against the skin on the cheeks, causing irritation or breakdown, particularly if the tubing is too tight or not positioned correctly.

E. Tops of the ears should also be observed. The tubing of the nasal cannula can cause pressure on the ears, especially if the tubing is looped behind the ears, leading to irritation or skin breakdown.

A. A private room with both contact and airborne precautions. B. A semiprivate room with a roommate who has the same diagnosis and airborne precautions. C. A private room with both standard and droplet precautions. D. A semiprivate room with a roommate who has the same diagnosis and contact precautions.

Correct Answer is A

Explanation

A. A private room with both contact and airborne precautions is appropriate for a client with varicella zoster virus (chickenpox or shingles in an immunocompromised state). This virus can spread through direct contact with lesions and airborne transmission of respiratory droplets.

B. A semiprivate room with a roommate who has the same diagnosis and airborne precautions could be considered if the roommate also has the same strain of the virus, but a private room is generally preferred to minimize cross-contamination risks.

C. A private room with both standard and droplet precautions is insufficient. Airborne precautions are necessary because varicella zoster virus can spread via airborne routes.

D. A semiprivate room with a roommate who has the same diagnosis and contact precautions does not account for the airborne transmission risk, making this option inappropriate.

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The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

Correct Answer is A

Explanation

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