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 D

Explanation

A. Gastric Irritation.

While gastric irritation is a common side effect of prednisone, it is not as critical as some other potential adverse effects and can often be managed with medication or dietary changes.

B. Moon facies.

Moon facies is a sign of Cushing's syndrome, a potential long-term side effect of prednisone, but it does not require immediate reporting compared to more acute symptoms.

C. Abdominal striae.
Abdominal striae (stretch marks) are a long-term side effect of corticosteroids like prednisone, but they are not typically an urgent concern.

D. Rapid weight gain.

This is the correct answer because rapid weight gain can indicate fluid retention, which may be a sign of more serious side effects such as heart failure or severe hypertension. It requires prompt medical attention to prevent further complications.

A. Encourage mobilization to prevent pulmonary embolism. B. Measure each calf's girth to evaluate edema in the affected leg. C. Observe for bleeding side effects related to heparin therapy. D. Assess blood pressure and heart rate at least every 4 hours.

Correct Answer is C

Explanation

A. Encourage mobilization to prevent pulmonary embolism.
While mobilization can be important in preventing further DVT development, initial bed rest is often recommended to avoid dislodging the clot. Mobilization should be carefully managed based on the provider's recommendations.

B. Measure each calf's girth to evaluate edema in the affected leg.
Measuring calf girth is useful for monitoring the extent of the DVT, but it is not the most critical intervention compared to monitoring for complications of heparin therapy.

C. Observe for bleeding side effects related to heparin therapy.
This is the correct intervention. Heparin is an anticoagulant, and monitoring for signs of bleeding (such as in the gums, urine, stool, and bruising) is crucial to prevent serious complications.

D. Assess blood pressure and heart rate at least every 4 hours.
While important, frequent monitoring of vital signs is secondary to the need to vigilantly observe for bleeding, which is a direct and significant risk of heparin therapy.

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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

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

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