A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?
Select a quiet location to talk to the client while remaining visible to staff members.
Give the client several clear options.
Observe the client and the situation.
Respect the client's personal space.
The Correct Answer is C
Rationale:
A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.
B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.
C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.
D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.
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Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. Administering methylergonovine maleate is appropriate if the uterus is boggy, as it helps to promote uterine contractions and prevent postpartum hemorrhage.
B. Massaging a firm fundus is incorrect; instead, the nurse should massage a boggy (soft) fundus to encourage it to contract.
C. Documenting fundal height is essential to monitor the uterine involution and ensure the uterus is returning to its pre-pregnancy size.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal bleeding or clots, which may indicate complications.
E. Determining whether the fundus is midline is necessary to assess for displacement, which can affect uterine tone and bleeding.
Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.