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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.

A. Administer an antiemetic to prevent vomiting. B. Report the complaint of eye pain to the surgeon. C. Apply bilateral eye shields to reduce photosensitivity. D. Begin postoperative prophylactic antibiotics.

Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?

Correct Answer is B

Explanation

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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?