The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first?

Choice A reason: Limiting fluid intake to prevent incontinence is not the highest priority intervention for this client because it can cause dehydration, urinary tract infections, or kidney stones, which can worsen the client's condition and quality of lifE. The client should be encouraged to drink adequate fluids and empty their bladder regularly.

Choice B reason: Providing regular perineal care to prevent skin breakdown is the highest priority intervention for this client because it can prevent infection, irritation, and ulceration of the skin around the genital and anal areas, which can cause pain, discomfort, and complications. The client should be kept clean and dry, and use barrier creams or pads as needeD.

Choice C reason: Administering hypotonic IV fluids is not an intervention for this client because it can cause fluid overload, hyponatremia, or cerebral edema, which can endanger the client's health and safety. The client does not need IV fluids unless they are dehydrated or have other indications.

Choice D reason: Teaching Kegel exercises to strengthen the pelvic floor is not an intervention for this client because it can be ineffective or harmful for clients with reflex incontinence, which is caused by loss of voluntary control over bladder contractions due to spinal cord injury. The client may benefit from other interventions such as bladder training, medication, or surgery.

The correct answer and explanation is:

d) Ask when the nurse should return. Correct

This is the action that the PN should take when entering the client's room and finding the couple in bed together. Asking when the nurse should return respects the client's privacy, dignity, and autonomy, while also ensuring that the client receives the necessary care.

The PN should acknowledge that the client has the right to express her sexuality and intimacy, as long as it is consensual and safe . The PN should also avoid making any judgments or assumptions about the client's relationship or preferences.

a) Request that the man get up and leave.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Requesting that the man get up and leave is rude, disrespectful, and intrusive, as it violates the client's privacy, dignity, and autonomy. The PN should not interfere with the client's sexual or intimate activities, unless there is a clear indication of abuse, coercion, or harm.

b) Report the incident to the family.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Reporting the incident to the family is inappropriate and unethical, as it breaches the client's confidentiality and autonomy. The PN should not share any information about the client's sexual or intimate activities with anyone without her consent, unless there is a clear indication of abuse, coercion, or harm.

c) Exit the room and quietly close the door.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Exiting the room and quietly closing the door is passive and neglectful, as it ignores the client's needs and care.

The PN should not avoid or delay providing care to the client because of her sexual or intimate activities, unless she requests so . The PN should also communicate with the client and her partner in a respectful and professional manner.