The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?
Request a spiritual advisor's consult.
Encourage viewing of the body to accept the death.
Provide support of the spouse's feelings.
Ask the relatives about how the spouse is coping.
The Correct Answer is C
A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.
B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.
C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.
D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.3"]
Explanation
Rationale:
- Convert the infant's weight from pounds (lb) to kilograms (kg).
Weight in kg = 22 lb / 2.2 lb/kg
= 10 kg.
- Calculate the total daily desired dose in milligrams (mg).
Total daily desired dose (mg) = Desired dose (mg/kg/day) × Weight (kg)
= 20 mg/kg/day × 10 kg
= 200 mg/day.
- Determine the number of doses per day.
Doses are given every 8 hours, so Number of doses per day = 24 hours / 8 hours/dose
= 3 doses/day.
- Calculate the dose per administration in milligrams (mg).
Dose per administration (mg) = Total daily desired dose (mg) / Number of doses per day
= 200 mg / 3 doses
= 66.666 mg.
Available concentration of the medication = 250 mg / 5 mL.
- Calculate the volume in milliliters (mL) to administer per dose.
Volume (mL) = Desired dose per administration (mg) / (Available concentration (mg) / Available volume (mL))
= 66.666 mg / (250 mg / 5 mL)
= 66.666 mg / 50 mg/mL
= 1.333 mL.
- Round the answer to the nearest tenth.
= 1.3
Correct Answer is ["B","C","D"]
Explanation
A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.
B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.
C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.
D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.
E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.
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