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?

Consult with the charge nurse about implementing suicide precautions.

Sit quietly in the client's room until the client is ready to verbalize his feelings.

Leave the room after offering to return to the client's room at a later time.

Notify a member of the client's family of the need to come to stay with the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.

Choice A rationale:

Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.

Choice B rationale:

Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.

Choice C rationale:

Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.

Choice D rationale:

Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.

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Correct Answer is A

Explanation

Choice B rationale:

The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.

Choice C rationale:

Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.

Choice D rationale:

The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is moreappropriate for this purpose.

A. Monitor the client's temperature hourly. B. Offer the client fluids frequently. C. Provide care to moisten oral mucosa. D. Report the findings to the charge nurse.

Correct Answer is D

Explanation

Correct Answer: D. Report the findings to the charge nurse.

Choice A rationale:

Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.

Choice B rationale:

Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.

Choice C rationale:

Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.

Choice D rationale:

Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is admitted to an acute care facility with the diagnosis of left lower lobe pneumonia. How should the practical nurse (PN) position the client for auscultation of posterior lung fields?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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