Nokea
The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?
- A. Bring the swaddled fetus to the mother
- B. Explain that the cause of death must be determined before she can see the baby
- C. Ask her if she is sure she wants to see the baby
- D. Tell her it would be better to wait until she is in her room before she sees the baby
Correct Answer: A
Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.
You may also like to solve these questions
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
- A. Wearing clean gloves while performing a heel stick on an infant
- B. Wearing the same gloves for assessments of clients in the same room
- C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
- D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus
Correct Answer: A
Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from which of the following clients?
- A. A 6-year-old who drank some diluted bleach.
- B. A 10-year-old who suffered burns in a house fire.
- C. A 12-year-old who fractured his arm in a fight at school.
- D. A 12-month-old without any oral intake for the last 12 hours.
Correct Answer: A
Rationale: For children under 7 years, most states have laws that mandate reporting certain situations to social services or child protection, such as ingestions of toxic substances, fractures, suspected neglect, or abuse, and burns. In this scenario, the 6-year-old who drank diluted bleach falls under the category that requires a social service consult. The other choices involve injuries or conditions that may warrant medical attention but do not necessarily mandate a social service consult based on age-related legal requirements.
After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?
- A. The client's prior experiences with outpatient surgery
- B. The client's medical plan and the extent of coverage for outpatient surgery
- C. The client's plan for transportation and care at home
- D. The client's plan to spend the night at the surgical center
Correct Answer: C
Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.
What task should the RN perform first?
- A. Changing a burn dressing that is scheduled every four hours.
- B. Doing pinsite care on a client in skeletal traction ordered TID.
- C. Teaching a newly diagnosed diabetic about diet and exercise.
- D. Assessing a newly admitted client.
Correct Answer: D
Rationale: The correct answer is to assess a newly admitted client first. When a client is newly admitted, it is crucial to perform an assessment promptly. The initial assessment and establishment of a care plan should be completed within a specific timeframe to ensure the client's needs are met effectively. Choices A, B, and C involve important tasks but should be prioritized after the initial assessment of the newly admitted client to ensure timely and appropriate care delivery. Changing a burn dressing (Choice A) and doing pinsite care on a client in skeletal traction (Choice B) are time-sensitive tasks but can be safely delayed briefly to conduct the initial assessment. Teaching a newly diagnosed diabetic about diet and exercise (Choice C) is important for the client's long-term care but can be scheduled after the immediate needs assessment of the newly admitted client.
The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not "Jesus"?.
- D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct Answer: A
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.