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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.
Choice B rationale:The nebulizer treatment should be administered FIRST to alleviate the clients obstructed airway (respiratory distress)
Choice C rationale: Evaluating the breathing pattern is important but should be done immediately after implementing physician orders
Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.
Correct Answer is C
Explanation
Choice A rationale: Asking the nurse to explain thoughts on the need for an in-service program encourages open communication and allows the nurse-manager to address specific concerns.
Choice B rationale: Choosing to send another nurse may not address the concerns of the nurse expressing dissatisfaction and may not promote a collaborative approach. Choice C rationale: Encouraging the nurse to share concerns and discuss ways to prepare for emergencies fosters open communication and allows for constructive dialogue.
Choice D rationale: Informing the nurse that in-service is not optional and attendance is mandatory may create resistance and does not promote a collaborative approach to addressing concerns.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.