An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?
Report the incident to the family.
Request that the man get up and leave.
Exit the room and quietly close the door.
Ask when the nurse should return.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Extend the leg and flex the foot.
Choice A rationale:
Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.
Choice B rationale:
Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.
Choice C rationale:
Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.
Choice D rationale:
Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.
: 3
Correct Answer is C
Explanation
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
: 1
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