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

Ask the client if he is currently hearing voices.

Have the unlicensed assistive personnel (UAP) escort the client down to his room.

Record the event but do not disturb the client.

Administer an as-needed (PRN) dose of haloperidol.

Answer and Explanation

The Correct Answer is A

The appropriate action for the practical nurse (PN) in this situation would be to ask the client if he is currently hearing voices. This step is important to assess the client's current state and gather information about his experiences. By directly asking the client about hearing voices, the PN can gain insight into the client's symptoms and determine if there is a need for further intervention or support.
B. Having the unlicensed assistive personnel (UAP) escort the client to his room may not be necessary at this point, as the client may simply be engaging in self-talk or may prefer some time alone. However, if the client's behavior becomes disruptive, agitated, or poses a safety risk, involving the UAP or taking other appropriate measures may be warranted.
C. Recording the event is important for documentation purposes, but it should not be the only action taken. It is crucial to actively assess the client's well-being and address any potential concerns or needs.
D. Administering an as-needed (PRN) dose of haloperidol without further assessment or consulting the healthcare provider would be inappropriate. Medication decisions should be based on a comprehensive evaluation of the client's symptoms and the healthcare provider's recommendations.

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Correct Answer is B

Explanation

Monitoring the client's vital signs, including temperature, heart rate, respiratory rate, and blood pressure, is crucial to assess for any signs of infection or complications following surgery.
A. While fluid volume intake and output are important to monitor for overall hydration status, it is not the most immediate concern after reinforcing the dressing.
C. Similarly, assessing the volume of peripheral pulses is important to evaluate peripheral perfusion, but it may not be the highest priority at this time.
D. Incisional pain scale rating is important to assess the client's comfort and pain level, but it should be done after ensuring the security of the surgical dressing.

A. Apply gloves and empty the drainage bag. B. Remove the looped tubing from the bed. C. Measure the urinary output in the bag. D. Attach the drainage bag to the bed frame.

Correct Answer is D

Explanation

This is the action that the PN should implement when assessing a client with an indwelling urinary catheter and observing that the catheter drainage bag, which is half-full, is attached to the side rail and the tubing is looped on the bed. Attaching the drainage bag to the bed frame ensures that the bag is below the level of the bladder and prevents backﬂow of urine, which can cause infection or obstruction. The PN should also straighten the tubing and avoid any kinks or loops that may interfere with the drainage.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take?

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A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "WOW! You have big breasts." Which response is best for the PN to provide?

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?