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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

A. Oﬀering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.

A. Obtain a post-voided residual (PVR) volume. B. Teach the client with fluid restrictions how to measure urine output. C. Empty bedside drainage unit for a client with an indwelling urinary catheter. D. Irrigate an indwelling urinary catheter for a client with bladder suspension. E. Transport a urine culture sample to the laboratory.

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.

Choice B rationale:

Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).

Choice C rationale:

Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.

Choice D rationale:

Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.

Choice E rationale:

Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

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?

The practical nurse (PN) receives a report of a stable client who experienced partial burn thickness over 30% burns body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

A client reports feeling numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) review before reporting the finding?

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

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The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?

An older client is admitted to an acute care facility with the diagnosis of left lower lobe pneumonia. How should the practical nurse (PN) position the client for auscultation of posterior lung fields?