A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

“I can arrange for a male AP to assist with your personal hygiene care.”

“Could you explain why you prefer not to have a female AP assigned to your care?”

“The AP assigned to you is highly competent and has experience caring for male patients.”

“I will inform the charge nurse about your request to have only male staff members assigned to your care.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Respects patient autonomy: This response directly addresses the patient's preference and demonstrates respect for their right to make decisions about their own care. It empowers the patient by offering a solution that aligns with their stated wishes.

Promotes patient comfort: By accommodating the patient's preference, the nurse can help to create a more comfortable and trusting environment, which can lead to better patient outcomes.

Protects patient privacy: Personal hygiene care often involves exposure of sensitive body parts and can be a source of embarrassment or anxiety for some patients. Ensuring that the patient is comfortable with the gender of the caregiver helps to protect their privacy and dignity.

Demonstrates cultural sensitivity: While not explicitly stated in the question, it's possible that the patient's preference is rooted in cultural or religious beliefs. Being sensitive to these factors is essential for providing culturally competent care.

Provides a practical solution: This response offers a concrete solution that can be easily implemented, ensuring that the patient's needs are met in a timely and efficient manner.

Choice B rationale:

May be perceived as intrusive: Asking the patient to explain their reasoning could make them feel uncomfortable or defensive. It's important to respect the patient's right to privacy and not pressure them to disclose personal information.

Could delay care: While understanding the patient's reasons may be helpful in some cases, it's not essential for providing appropriate care. Delaying care to gather this information could potentially compromise the patient's well-being.

Choice C rationale:

Dismisses patient's concerns: This response fails to acknowledge the patient's preference and could make them feel unheard or disrespected. It's important to validate the patient's feelings and concerns, even if you don't fully understand them.

May not address underlying issues: The patient's preference may be based on factors that are not related to the AP's competence or experience. Simply stating the AP's qualifications is unlikely to resolve the patient's concerns.

Choice D rationale:

Defers responsibility: While informing the charge nurse may be necessary for logistical reasons, it's important for the nurse to take ownership of the situation and address the patient's concerns directly. Deferring to another staff member could make the patient feel like their concerns are not being taken seriously.

May delay care: Involving additional staff members could potentially delay the patient's care. It's more efficient to address the patient's preference directly, if possible.

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Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

A. Distended neck veins B. Bounding pulse C. BP 146/94 mm Hg D. Urine specific gravity 1.034 .

Correct Answer is D

Explanation

Choice A rationale:

Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.

In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.

It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.

Choice B rationale:

A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.

A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.

Choice C rationale:

A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:

Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.

A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.

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A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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