The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?
Report the incident and the UAP for further action by the nurse manager.
Tell both of them to lower their voices in consideration of other residents.
Tell the resident and the UAP that shouting is not permitted.
Enter the room and tell the UAP to leave the room immediately.
The Correct Answer is D
When the PN witnesses a situation where a resident is shouting profanities and a staff member (UAP) responds inappropriately, the immediate priority is to ensure the safety and well-being of the resident. It is essential to address the situation promptly and prevent further escalation.
Entering the room and instructing the UAP to leave immediately serves several purposes:
1. Protecting the resident: Removing the UAP from the room ensures that the resident is not subjected to further conflict or distress.
2. Maintaining a calm and therapeutic environment: By addressing the disruptive behavior and removing the staff member involved, the PN can help restore a peaceful environment for the resident and other individuals in the facility.
3. Ensuring professional conduct: Shouting and engaging in unprofessional behavior is not acceptable in a healthcare setting. By immediately intervening and directing the UAP to leave the room, the PN reinforces the importance of maintaining a respectful and professional approach to caregiving.
After addressing the immediate concern, the PN should follow up by reporting the incident and providing a detailed account to the nurse manager or supervisor. This allows for appropriate action to be taken, such as further investigation or disciplinary measures if necessary.
The other options mentioned are not the first actions to be taken in this situation:
A. Reporting the incident and the UAP for further action by the nurse manager: While reporting the incident is important, it is not the immediate action required to address the situation in
real-time.
B. Telling both of them to lower their voices in consideration of other residents: While promoting a calm environment is important, addressing the issue of shouting and unprofessional behavior takes precedence over requesting a volume reduction.
C. Telling the resident and the UAP that shouting is not permitted: While it is essential to communicate the expectations of behavior, the immediate focus should be on removing the staff member from the situation and ensuring the resident's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The presence of a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor indicates the possibility of infection in the wound. Evaluating the client's C-reactive protein (CRP) level can provide information about the presence and severity of inflammation and infection. CRP is an acute-phase reactant produced by the liver in response to inflammation. An elevated CRP level suggests an active inflammatory process, which can help in determining the need for further assessment and treatment, such as wound cultures or antibiotics.
Here's why the other options are incorrect:
B- Serum blood glucose (BG) level: While diabetes and elevated blood glucose levels can increase the risk of infection and delay wound healing, in this case, the presentation of redness, swelling, drainage, and odor suggests a possible wound infection. Evaluating the client's blood glucose level is important for the overall management and control of diabetes, but it is not the first priority when assessing a potentially infected wound.
C- Serum albumin: Serum albumin is a measure of the client's nutritional status and can provide information about the client's overall protein levels. While malnutrition can affect wound healing, in this scenario, the priority is to assess for signs of infection and inflammation. Addressing the wound infection takes precedence over evaluating the client's serum albumin level.
D- Culture for sensitive organisms: Obtaining a wound culture for sensitive organisms may be necessary to identify the specific bacteria causing the infection and determine the appropriate antibiotic treatment. However, before performing a wound culture, it is important to assess the severity of the wound infection and determine the need for further intervention. Evaluating the client's CRP level is a more immediate and readily available assessment to determine the presence and severity of inflammation.
Correct Answer is C
Explanation
The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.
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