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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Correct Answer is C

Explanation

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

A. Gives the client a hug and says, "It is okay to cry when you are sad." B. While touching the client's forearm, asks, "Would you like to talk about it?" C. "This is a bad time. I can see you are upset. I can come back later." D. "I am sorry to disturb you at a difficult time. This can wait until later."

Correct Answer is B

Explanation

A. Gives the client a hug and says, "It is okay to cry when you are sad" may seem comforting but could invade the client’s personal space and may not be appropriate in a professional setting without the client’s consent.

B. While touching the client's forearm, asks, "Would you like to talk about it?" is correct because it shows empathy, provides emotional support, and invites the client to share their feelings. The light touch conveys care without being intrusive.

C. "This is a bad time. I can see you are upset. I can come back later" dismisses the client’s emotional needs and prioritizes the nurse’s schedule over the client’s well-being.

D. "I am sorry to disturb you at a difficult time. This can wait until later" acknowledges the client’s emotions but does not provide immediate support or address their needs effectively.

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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 notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Correct Answer is C

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Correct Answer is B

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