While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.
What is the most appropriate action for the nurse to take?
Reassure the client that the nurse will return after all vital signs are taken.
Pull up a chair and sit beside the client’s bed.
Allow the client to hold the nurse’s hand until the vital signs can be completed.
Tell the client that he must release the nurse’s hand.
The Correct Answer is B
Choice A rationale
Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.
Choice B rationale
Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.
Choice C rationale
Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.
Choice D rationale
Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Based on the provided information, the following notations require immediate follow-up:
- Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
- Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
- Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.
Correct Answer is B
Explanation
Choice A rationale
Exercise is an important part of managing type 2 diabetes as it helps regulate blood glucose levels. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also helps your body use insulin more efficiently. Therefore, the statement “Remember exercise will not affect blood glucose levels” is incorrect.
Choice B rationale
Moderate alcohol consumption is generally safe for most people with diabetes. A moderate amount of alcohol is up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Too much alcohol can cause blood sugar levels to drop too low and can also increase the risk of other health problems.
Choice C rationale
While it’s important to keep wounds clean and covered, using antibiotic ointment on every wound isn’t always necessary. Overuse of antibiotics can lead to antibiotic resistance. It’s best to consult with a healthcare provider for wound care advice.
Choice D rationale
Soaking feet in hot water can lead to burns or infections, especially if the person has neuropathy. It’s recommended to wash feet with warm — not hot — water and dry them gently, especially between the toes.
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