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 B

Explanation

Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.

Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.

A. Fluid volume deficit. B. Impaired bed mobility. C. Caregiver role strain. D. Bowel incontinence.

Correct Answer is A

Explanation

Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.

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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

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

Correct Answer is B

Explanation

Correct Answer is A

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?