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

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Oﬀering the client a prescribed sleep medication is not the best initial intervention because it may have side eﬀects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caﬀeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caﬀeinated beverages to the client before bedtime.

A. Perform standard hand washing. B. Put on disposable gown. C. Remove gloves and gown in the room. D. Don a pair of procedure gloves.

Correct Answer is A,B,D,C

Explanation

= The correct sequence is: A. Perform standard hand washing, B. Put on disposable gown, D. Don a pair of procedure gloves, C. Remove gloves and gown in the room.

Choice A rationale:

Performing standard hand washing before donning personal protective equipment (PPE) is essential to ensure that the UAP's hands are clean before putting on gloves and gown.

Choice B rationale:

Putting on a disposable gown is the next step after hand washing to protect the UAP's clothing from potential contamination.

Choice D rationale:

Donning a pair of procedure gloves is the next step after putting on the gown to protect the UAP's hands from contact with potentially infectious material.

Choice C rationale:

Removing gloves and gown in the client's room is the last step in the sequence. This step ensures that any potential contaminants stay within the isolation room and do not spread to other areas of the facility.

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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

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

Correct Answer is B

Explanation

Correct Answer is A,B,D,C

Explanation

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