Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?

Ignore the behavior and proceed with the IV antibiotic administration.

Instruct the patient to cease the inappropriate behavior.

Exit the room and close the door quietly.

Fill out an unusual occurrence report.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.

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Correct Answer is D

Explanation

Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale

A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.

A. Obtain an analgesic prescription. B. Infuse an intravenous fluid bolus. C. Administer PRN oral antipyretic. D. Cover client with a cooling blanket.

Correct Answer is B

Explanation

Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.

Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.

Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.

Choice D rationale

Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.

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Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor. What should be the nurse’s course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?