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
Explanation
A. Cleansing the site and covering with a sterile towel is typically done by the healthcare provider performing the procedure.
B. Gathering the procedure tray and equipment ensures everything necessary for the thoracentesis is ready.
C. Placing the client in an orthopneic position may be part of the positioning during the procedure but is not the primary preparation.
D. Keeping the client NPO and encouraging voiding might be necessary for some procedures but isn't specific to thoracentesis preparation.
Correct Answer is A
Explanation
A. Checks the medical record for the correct signed consent form prior to the examination. - Verifying that the correct consent form is signed and present in the medical record before the invasive examination is crucial to ensure the procedure is performed with proper authorization.
B. Explains the examination and asks the client to sign the consent form. - While it's important to explain the examination, obtaining consent typically involves the healthcare provider or a designated professional.
C. Explains to a family member and obtains their signature on the consent form. - Consent generally needs to be obtained directly from the client or their legally authorized representative, not just a family member.
D. Asks if the client understands the exam and why the consent form must be signed. - While educating the client about the procedure and the purpose of consent is important, it doesn't cover the formal process of obtaining and verifying the consent form.
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