Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Instruct the UAP to ask the visitor to get off the client's bed.

Discuss why visitors should not lie in the bed with the client.

Explain that the client has the right to have a visitor lie on the bed.

Notify the charge nurse that the visitor is lying on the client's bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.

Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.

Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.

Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.

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Correct Answer is D

Explanation

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

A. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute. B. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain. C. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced. D. After ambulating, a postoperative client grimaces and reports incisional pain at a "9" on a ten-point scale.

Correct Answer is B

Explanation

Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.

Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.

Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica

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Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

Correct Answer is D

Explanation

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

Correct Answer is B

Explanation

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