An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

Choice A rationale:

Reporting the incident to the family is not the first action the PN should take in this situation. It may be appropriate to inform the family later if necessary, but immediate action is needed to address the boundaries being crossed in the client's room.

Choice B rationale:

Requesting that the man get up and leave is not the first action the PN should take. This situation involves delicate and sensitive issues, and the PN should prioritize the client's privacy, dignity, and emotional well-being.

Choice C rationale:

The most appropriate first action is for the PN to exit the room and quietly close the door. This action respects the client's privacy and allows the couple to have some space and time to compose themselves.

Choice D rationale:

Asking when the nurse should return is not the first action to take. The PN needs to ensure the client's privacy and deal with the situation at hand discreetly. Later, the PN can discuss the incident with the client if necessary, or involve the appropriate authorities as per the facility's policy.

This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.

A. An abduction pillow is placed between the client's legs when positioned correctly and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.

C. A turning sheet is used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.

D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.