A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?

When the practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) consistently records subnormal temperatures when using the thermometer, the first action the PN should take is to observe how the UAP obtains temperatures. This allows the PN to directly assess the UAP's technique and determine if any errors or inaccuracies are occurring during temperature measurement. By observing the process, the PN can identify any potential issues, such as incorrect placement of the thermometer or improper technique, and provide appropriate guidance and education.

The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.

Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.

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B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.

C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.

Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.

D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.