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 C

Explanation

A. Phobia.
A phobia is an irrational fear of a specific object, situation, or activity that leads to a desire to avoid it. The client's behavior is more characteristic of a compulsion rather than a phobia.

B. Obsession.
An obsession is an intrusive, unwanted thought, image, or urge that causes significant anxiety.
While the client's fear of contamination could be an obsession, the handwashing itself is a compulsion.

C. Compulsion.
This is the correct answer because a compulsion is a repetitive behavior or mental act that a person feels driven to perform in response to an obsession. The client's excessive handwashing ritual is a classic example of a compulsion.

D. Addiction.
Addiction involves a compulsive need for and use of a habit-forming substance or behavior, typically involving a sense of euphoria or pleasure, which is not applicable to the client's behavior.

A. Oxygen is less toxic when it is humidified with a hydration source. B. Avoid administration of oxygen at high levels for extended periods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs.

Correct Answer is B

Explanation

A. Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B. Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.

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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

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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