Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies.
What statements indicate the client's confusion is resolving?
Select all that apply.
Asks how long he has been in the hospital
Drinking broth
States he is hungry
Clawing at the air
Keeps trying to get out of bed to find the swimming pool
Recognizes his daughter
Oriented to time, place, and self
Oxygen saturation on 0.5L of 100%
Correct Answer : A,B,C,F,G
Based on the given information, the statements that indicate the client's confusion is resolving are:
- Asks how long he has been in the hospital: This shows cognitive awareness and the ability to ask relevant and coherent questions.
- States he is hungry: This indicates a return to normal appetite and the ability to recognize and express basic needs.
- Recognizes his daughter: This demonstrates the ability to recognize and identify a familiar individual, suggesting an improved level of cognitive functioning.
- Oriented to time, place, and self: Being aware of the current time, location, and personal identity reflects an improved level of orientation and mental clarity.
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The statement "Drinking broth" does reflect the client's willingness and ability to consume food.
The following statements suggest ongoing confusion or potential issues:
- Clawing at the air: This behavior may indicate restlessness, agitation, or disorientation.
- Keeps trying to get out of bed to find the swimming pool: This behavior may indicate confusion or an altered perception of reality.
The statement "Oxygen saturation on 0.5L of 100%" provides information about the client's oxygen saturation level but does not specifically address the resolution of confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.
E. This is a client care intervention that the PN can assign to the UAP. Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.

B. This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
C.This is not a client care intervention that the PN can assign to the UAP. Teaching the client with fluid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
D.This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile fluid into the bladder through the catheter to flush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
Correct Answer is ["B","C","E"]
Explanation
The practical nurse (PN) should provide the following instructions to the unlicensed assistive personnel (UAP) for cleaning the hearing aid of an older adult resident:
A- Keep the battery door closed during storage: his is incorrect because the battery door should be kept open when the hearing aid is not in use. Keeping it open helps prevent moisture buildup inside the device.
B- Remove ear wax from the device's surface: Earwax accumulation can affect the performance of the hearing aid. Instructing the UAP to clean the device's surface and remove any visible ear wax will help maintain optimal functioning.
C- Verify that the device is labeled with the client's identification: Labeling the device with the client's identification is crucial to ensure that it is returned to the correct person. This step helps prevent mix-ups or misplacements of hearing aids among residents.
D- This is not appropriate as it can expose the device to heat and sunlight, which could damage it.
E- Observe and report any ear drainage after removing the device: After removing the hearing aid, the UAP should observe the client's ears for any signs of drainage or abnormal discharge. If ear drainage is noticed, it should be reported to the PN or appropriate healthcare provider for further assessment and management.
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