The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?

Include "Noncompliance”. as a priority problem in the client's plan of care.

Advise the UAP to re-attempt the daily weight after the client eats breakfast.

Consult with the client about the reasons for his refusal to be weighed

Calculate the client's weight based on the 24-hour fluid intake and output.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.

Choice A rationale:

Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.

Choice B rationale:

Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.

Choice C rationale:

Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.

Choice D rationale:

Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.

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Correct Answer is B

Explanation

Choice A rationale:

Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.

Choice B rationale:

Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.

Choice C rationale:

Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.

Choice D rationale:

Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.

A. Small gauze pad. B. Paper tape. C. Three mL syringe. D. Exam gloves. E. Sterile gloves.

Correct Answer is ["A","B","D"]

Explanation

These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.

C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.

E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.

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The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client states, "I should use these drops to anesthetize my eye if I experience eye pain.”. Which action should the PN implement?

Correct Answer is B

Explanation

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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