A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?
A client who has a prescription for compression stockings and did not receive them.
A client who consumes all the food from their meal tray.
A client who requests to sit in the bedside chair while watching TV.
A client who requests assistance to use the bedside commode.
The Correct Answer is A
Choice A rationale:
The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.
Choice B rationale:
Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.
Choice C rationale:
The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.
Choice D rationale:
A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to abstain from sexual intercourse for one month is not necessary for the management of Chlamydia trachomatis. Instead, the client should be advised to abstain from sexual activity until they and their partner(s) have completed the prescribed course of antibiotics and are no longer contagious, which is usually within 7 days.
Choice B rationale:
Administering ceftriaxone via intermittent IV bolus is not the recommended route for treating Chlamydia trachomatis. The standard treatment for Chlamydia trachomatis infection is oral antibiotics, such as azithromycin or doxycycline. Intravenous administration is not typically required for uncomplicated cases.
Choice C rationale:
Scheduling the client for retesting in one week is not necessary if the client has received appropriate treatment and follows the prescribed course of antibiotics. Retesting is generally recommended 3 months after treatment, especially in cases of persistent or recurrent symptoms.
Choice D rationale:
Reporting the infection to the state department of health is a crucial action. Chlamydia trachomatis is a reportable sexually transmitted infection in many jurisdictions. Reporting helps public health authorities track the incidence of the disease, implement preventive measures, and allocate resources effectively to control its spread within the community. It is essential for the nurse to comply with legal and ethical obligations by reporting the infection to the appropriate health authorities.
Correct Answer is B
Explanation
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
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