A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Instruct the client to report the theft to the police

Report the possible abuse to adult protective services.

Ask the client if there is another family member they can call for financial help.

Restrict visitation for the client's family until discharge.

Answer and Explanation

The Correct Answer is B

The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.

a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.

c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.

d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.

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Correct Answer is B

Explanation

The instruction that the nurse should include is "You can take a shower 1 day after your procedure." According to the Cleveland Clinic, the morning after the procedure, the client may take the dressing oﬀ the catheter insertion site. The easiest way to do this is when showering, get the tape and dressing wet and remove it.

Option a is incorrect because there is no information suggesting that a client must wait 3 days before resuming a regular diet after a cardiac catheterization.

Option c is incorrect because according to the Cleveland Clinic, clients should gradually increase their activities until they reach their normal activity level within one week after the procedure.

Option d is incorrect because there is no information suggesting that a client must wait 1 week before returning to school after cardiac catheterization.

A. Collect 2 ml of sputum in an emesis basin B. Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection C. Swab the oropharynx with a sterile swab D. Refrigerate the specimen until the time of transport to the laboratory

Correct Answer is D

Explanation

Answer: (D) Refrigerate the specimen until the time of transport to the laboratory

Rationale:

A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.

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A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching for an adolescent who is scheduled for a cardiac catheterization. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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