A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

Correct Answer: A

Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.

Correct Answer: A

Rationale: In this scenario, the correct response is option A: "The ingested children's chewable vitamins contain iron." This information should be immediately reported to the physician because iron toxicity can be a serious and potentially life-threatening condition, especially in children. Iron overdose can lead to gastrointestinal symptoms, metabolic acidosis, cardiovascular collapse, and even death if not promptly treated. Therefore, notifying the physician about the ingestion of iron-containing vitamins is crucial for timely intervention and management. Option B, "The child has been treated several times for ingestion of toxic substances," while concerning, is not as immediately critical as ingesting iron. Option C, "The child has been treated several times for accidental injuries," does not pertain to the current situation of potential toxicity. Option D, "The child was nauseated and vomited once at home," is a common symptom post-ingestion but does not provide crucial information about the specific substance ingested, unlike the iron in this case. In an educational context, understanding the significance of reporting specific information to healthcare providers is vital for healthcare professionals, especially in emergency situations. This question highlights the importance of thorough assessment and prompt communication to ensure appropriate interventions and patient safety. Nurses and other healthcare providers must be able to prioritize and communicate critical findings effectively to optimize patient outcomes.

Correct Answer: D

Rationale: The correct answer is option D: Administer IV fluid support with supplemental thiamine as ordered. In this scenario, the patient is likely presenting with symptoms of alcohol withdrawal syndrome, which can lead to severe complications like delirium tremens. Administering IV fluid support helps to prevent dehydration and maintain electrolyte balance, while thiamine supplementation is crucial in preventing Wernicke's encephalopathy, a common complication of alcohol withdrawal. Option A: Obtaining an order for a blood alcohol level may be important for assessing the patient's alcohol intoxication status but is not the priority in managing acute alcohol withdrawal. Option B: Contacting the family for additional history is valuable for holistic care but does not address the immediate physiological needs of a patient experiencing alcohol withdrawal. Option C: Administering naloxone (Narcan) is used to reverse opioid overdose, not alcohol withdrawal symptoms. It is not indicated in this situation. Educationally, understanding the priority actions in managing alcohol withdrawal is essential for nurses caring for patients in acute care settings. Recognizing the signs and symptoms of withdrawal, and knowing the appropriate interventions, can help prevent severe complications and improve patient outcomes. Learning to prioritize interventions based on patient needs is a crucial skill in nursing practice.

Correct Answer: C

Rationale: In the context of delegation in nursing, it is crucial to understand the scope of practice for different levels of nursing personnel. In this scenario, the most appropriate task to delegate to an LPN/LVN is option C) Remove wet clothing and cover the victim with a warm blanket. This task falls within the scope of practice for an LPN/LVN as it involves basic patient care and does not require advanced assessment or critical thinking skills. LPNs/LVNs are trained to provide direct patient care, such as assisting with activities of daily living and maintaining the comfort and safety of patients. Option A, talking to a community group about water safety issues, involves health education and promotion, which is typically beyond the scope of practice for an LPN/LVN. Option B, stabilizing the cervical spine for an unconscious drowning victim, requires specialized knowledge and skills that are within the scope of practice for a registered nurse or higher level of care provider. Option D, monitoring an asymptomatic near-drowning victim, involves ongoing assessment and potential for changes in the patient's condition that may require immediate intervention or critical thinking skills beyond the scope of practice for an LPN/LVN. Understanding the delegation of tasks based on scope of practice is essential for safe and efficient patient care delivery in the healthcare setting. Nurses must know their own scope of practice as well as the scope of practice for other members of the healthcare team to ensure appropriate delegation and collaboration for optimal patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct priority intervention for the patient is option A) Transportation arrangements to a safe house. This choice is the most critical because it addresses the immediate safety and well-being of the patient. By ensuring the patient is in a secure environment, we can prevent further harm or danger. Option B) Referral to a counselor is not the priority in this situation because the patient's safety is at risk, and addressing their mental health needs should come after ensuring their physical safety. Option C) Advise about contacting the police may be necessary at some point, but it is not the priority intervention. The immediate focus should be on removing the patient from the dangerous situation. Option D) Follow-up appointment for injuries is also not the priority as the patient's safety is in jeopardy. Once the patient is in a safe environment, then follow-up care for injuries can be arranged. In an educational context, it is important for healthcare providers to prioritize actions that ensure patient safety in situations of abuse or danger. Understanding the hierarchy of needs and immediate interventions can help students and professionals make informed decisions in critical situations to provide the best possible care for their patients.