While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

Determine who is assigned the care of the client.

Enter the room and quietly observe the interaction.

Notify the hospital security department immediately.

Instruct the visitor to leave the room immediately.

Answer and Explanation

The Correct Answer is D

Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.

Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.

Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.

Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale: Recording the amount of daily wound drainage is important, but addressing the hemodynamic instability takes precedence in this situation. Choice B rationale: Replacing fluids intravenously based on intake and output is crucial to address the client's hypotension and potential dehydration.

Choice C rationale: Assessing skin condition and turgor for breakdown is important but may not address the immediate hemodynamic instability.

Choice D rationale: Turning every 2 hours around the clock from side-to-side is a general nursing intervention but does not directly address the client's hemodynamic instability.

A. Administered two medications to the same client at the wrong time. B. Changed work assignments without prior approval from charge nurse. C. Served a diet tray to a client who was NPO for a scheduled procedure. D. Documented data in the clinical record before assessing client's condition.

Correct Answer is C

Explanation

Choice A rationale: Administering two medications to the same client at the wrong time is a serious error, but it may not be the most critical issue for reporting to the Peer Review Committee (PRC).

Choice B rationale: Changing work assignments without prior approval may be a workplace issue but does not directly endanger patient safety, so it may not be the primary focus of the PRC.

Choice C rationale: Serving a diet tray to a client who is NPO is a serious error that can lead to complications and warrants reporting to the PRC.

Choice D rationale: Documenting data in the clinical record before assessing the client's condition may indicate a documentation error, but it does not pose an immediate risk to the patient's well-being.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

Correct Answer is C

Explanation

The nurse is caring for a client at the clinic who tests positive for the sexually transmitted infection (STI) trichomoniasis. The client reports having sex with multiple partners. Which response should the nurse provide?

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organizations budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?