The practical nurse (PN) reorients a male client to the correct time, day, date, location, and why he is here today but he is only able to remember his name and where he is. Based on these findings, what should the PN document?
Oriented x 3.
Oriented x 1.
Oriented x 2.
Oriented x 4.
The Correct Answer is C
A. Oriented x 3. - The client must recall the time, day, date, location, and reason for being there to be considered oriented x 3. As the client can only remember his name and location, it does not fulfill the criteria for oriented x 3.
B. Oriented x 1. - This is inaccurate as the patient is oriented in two aspects: person and place.
C. Oriented x 2. - The client recalls their name and place, hence is oriented in two aspects. This is therefore accurate.
D. Oriented x 4. - This would require the client to recall all four aspects of orientation (time, day, date, location, and reason for being there), which the client did not demonstrate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.
Correct Answer is D
Explanation
A. Checking the perineum for changes in "show" or discharge is important for monitoring labor progress, but it does not directly address the client's immediate need to empty her bladder. This action would be more relevant if there were signs of labor progression or complications.
B. Reviewing the fetal heart rate pattern is crucial for assessing fetal well-being, but it does not resolve the client's discomfort from a full bladder. While important, it does not address the specific request made by the client.
C. Obtain a straight catheter kit to empty her bladder is unnecessary since the client can ambulate and has expressed the desire to void. Catheterization is typically reserved for clients unable to void independently or when the bladder is distended and interfering with labor progression.
D. Assist the client up to the bathroom is the correct action. Allowing the client to empty her bladder helps facilitate labor progression, as a full bladder can impede fetal descent. Since the vaginal exam is unchanged and the client is stable, ambulation to the bathroom is safe and appropriate. Additionally, this action supports the client’s autonomy and comfort during labor.
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