When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Leave the room and close the door quietly.

Ignore the behavior and hang the IV antibiotic.

Complete an unusual occurrence report.

Tell the client to stop the inappropriate behavior.

Answer and Explanation

The Correct Answer is A

A.   Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B.   Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C.   Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D.   Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

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

Explanation

A. Instruct client and family to reconsider end of life choices.
This is not an appropriate intervention. In hospice care, the focus is on providing comfort and supporting the client’s and family’s current end-of-life choices rather than challenging them.

B. Encourage family to visit frequently.
Encouraging family visits can provide emotional support and comfort to the client, helping them cope with feelings related to death and dying.

C. Teach client how to use guided imagery.
Guided imagery can be a helpful technique for managing anxiety and emotional distress, offering the client a method to find peace and comfort.

D. Encourage family to bring the client old photographs.
Old photographs can help evoke positive memories and provide comfort, aiding the client in coping with feelings of death and dying.

E. Record the client's desire to live.
Recording the client's desires is important for documenting their wishes, but it is not an intervention that directly aids in coping with feelings related to death and dying.

A. Confirm that the gown is tied securely at the neck and waist. B. Help the UAP reposition the gown sleeve over the glove edges. C. Remind the UAP to wash hands frequently while in the room. D. Assist the UAP with the application of a face mask or face shield. E. None F. None

Correct Answer is A

Explanation

A. Confirming that the gown is tied securely at the neck and waist is correct. Properly securing the gown ensures full coverage and prevents gaps where contamination could occur. This step is crucial for maintaining effective contact precautions.
B. Helping the UAP reposition the gown sleeve over the glove edges is incorrect. Standard PPE protocol requires that gloves be worn over the gown sleeves to prevent exposure when the hands are raised or moved.
C. Reminding the UAP to wash hands frequently while in the room is incorrect. While hand hygiene is always important, ensuring proper PPE use is the immediate priority in this scenario.
D. Assisting the UAP with the application of a face mask or face shield is incorrect. Contact precautions do not require a mask or face shield unless there is a risk of splashes or sprays of infectious material.

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When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

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

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Correct Answer is A

Explanation

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