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 C
Explanation
A. Calling the charge nurse might be necessary, but the immediate action after a needlestick injury is to cleanse the affected area to minimize the risk of infection.
B. Observing the appearance of the injection site is important but not the first action following a needlestick injury.
C. Cleaning the finger with soap and water is the initial action to reduce the risk of infection following a needlestick injury.
D. Explaining the occurrence to the client is important but comes after taking care of the nurse's immediate health following a needlestick injury.
Correct Answer is D
Explanation
A. Ineffective pain management reported while using morphine PCA is concerning but may not be immediately life-threatening.
B. Inability to void after discontinuing an indwelling catheter should be addressed but might not require immediate attention.
C. Oral ice chips eaten after vomiting postoperatively might need monitoring, but it's not typically an urgent issue.
D. Coffee-ground secretions draining via nasogastric tube suction could indicate bleeding in the upper gastrointestinal tract, which requires immediate attention due to the potential for severe
bleeding.
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