A female client is admitted with abdominal pain, possibly due to a gastric ulcer. Two days after admission, the client reports feeling nervous and tremulous. Further assessment reveals that the client's family is bringing a gin and tonic each night to help her relax. Which action(s) should the nurse take? Select all that apply.

Ask the client if she has any alcohol in the room at this time.

Administer an PRN prescription for an antianxiety drug.

Inform the family that they are enabling the client.

Observe for signs to determine if client is inebriated.

Schedule a conference with the client and family members.

Answer and Explanation

Correct Answer : A,D,E

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.

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Free Nursing Study Resources

Correct Answer is B,A,D,C

Explanation

1. B. Verify the insulin prescription: The first step is to verify the prescription to ensure the correct type and dose of insulin before administering it. This ensures one is following the appropriate instructions.

2. A. Obtain blood glucose level: The next step is to check the client's blood glucose level to determine the amount of insulin needed based on the sliding scale.

3. D. Cleanse the selected site: After obtaining the blood glucose level, the next step is to prepare the injection site by cleaning it properly to prevent infection.

4. C. Draw insulin into insulin syringe: Finally, drawing the appropriate amount of insulin into the syringe, based on the sliding scale and the blood glucose level, to administer the injection.

A. Demonstrate to the PN how to position the client more effectively for the procedure. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Assume care of the client and assign the PN to the care of a different client.

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure:
The correct position for a sigmoidoscopy is the left lateral or Sims' position to allow easier access to the sigmoid colon. Demonstrating the correct position supports patient safety and provides teaching for the PN.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: Assistance is not the issue in this scenario; the problem lies in incorrect positioning. Assigning additional help does not address the need to correct the client's position.

C. Acknowledge that the PN has positioned the client safely and correctly: The flat prone position is not appropriate for a sigmoidoscopy. Acknowledging incorrect positioning would be unsafe and potentially delay the procedure or increase the risk of injury.

D. Assume care of the client and assign the PN to the care of a different client: This is an excessive response that undermines the PN’s role. The more constructive approach is to guide and support the PN through demonstration rather than reassignment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B,A,D,C

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

An older adult client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

When should intimate partner violence (IPV) screening occur?

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?