A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Ask the APs to discontinue the conversation.

Inform the client what has occurred.

Notify the client's provider.

Schedule a disciplinary conference for the APS.

Answer and Explanation

The Correct Answer is A

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

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Correct Answer is B

Explanation

A. A client who reports experiencing short-term memory loss:

Memory loss is a common issue in older adults and does not necessarily indicate elder abuse. While it is a concern that should be addressed, it may not be related to abuse unless there are specific circumstances suggesting mistreatment.

B. A client who is wearing urine-scented clothing.

Wearing urine-scented clothing can be indicative of neglect, which is a form of elder abuse. Neglect occurs when the basic needs of an older adult, such as hygiene and cleanliness, are not adequately met. The nurse should report this finding to the case manager so that appropriate interventions and assessments can be made to address the potential abuse or neglect.

C. A client who has fingernails that are discolored and broken:

Fingernail issues can have various causes, including medical conditions or self-neglect. Discolored and broken fingernails alone may not be conclusive evidence of elder abuse, and further assessment is needed to determine the cause.

D. A client who provides a detailed description of a recent fall at home:

While falls are a concern, providing a detailed description of a fall is not necessarily indicative of elder abuse. Falls can occur for various reasons, and additional assessment is needed to determine the circumstances surrounding the fall and whether abuse or neglect is involved.

Correct Answer is ["3"]

Explanation

To calculate the volume (mL) that the nurse should administer, we can follow these steps:

Convert the weight from pounds to kilograms.

1 lb = 0.453592 kg
165 lb×0.453592 kg/lb≈74.843 kg

Calculate the total dose using the weight and prescribed dose:

Total Dose (units)=Dose per kg×Weight (kg)
Total Dose=8 units/kg×74.843 kg≈598.744 units

Determine the volume using the concentration of the available solution:

Volume (mL)=Total Dose (units)/Concentration (units/mL)
Volume =598.744 units/200 units/mL ≈ 2.994 mL

Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.

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A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is caring for a group of older adult clients. The nurse should report which of the following clients to the case manager for findings consistent with elder abuse?

Correct Answer is B

Explanation

A nurse is preparing to administer calcitonin 8 units/kg IM to a client who weighs 165 lb. Available is 200 units/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

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