An adolescent client who recently lost most sight in both eyes has been admitted for evaluation. The nurse observes an unlicensed assistive personnel (UAP) who is assisting the client to walk in the hallway for the first time since admission, as seen in the picture. Which action should the nurse take?

Encourage the UAP to continue to assist the client down the hallway.

Demonstrate to the UAP how to assist the client with ambulation more safely.

Instruct the UAP to guide the client back to his room right away.

Advise the UAP to stay nearby but allow the client to ambulate independently.

Answer and Explanation

The Correct Answer is B

A.   While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B.   Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C.   This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D.   Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

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Correct Answer is B

Explanation

A. While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B. Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C. Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D. Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

A. Absorbent undergarments dry for 6 hours. B. Heel dressing saturated with serous drainage. C. Frequent request for medication to sleep. D. Confusion to time, place, and environment.

Correct Answer is D

Explanation

A. While the use of absorbent undergarments is relevant to managing urinary incontinence, having them dry for 6 hours indicates that they are performing their function well in terms of absorbing urine. This finding does not immediately suggest a new issue that needs urgent further assessment.
B. A heel dressing saturated with serous drainage suggests that the stage II pressure ulcer on the left heel is producing a significant amount of fluid. Serous drainage is typically clear or light yellow and can indicate a wound that is still in the inflammatory phase of healing
C. Frequent requests for sleep medication can indicate issues with sleep patterns or underlying psychological stress. While it’s important to address sleep difficulties, this finding might not be as immediately critical as other concerns but warrants further assessment to address possible underlying causes and manage sleep issues appropriately.
D. Confusion about time, place, and environment in a newly admitted client is a significant finding and requires urgent further assessment. This level of confusion could be indicative of a serious issue such as delirium, which can be caused by various factors including infection, dehydration, metabolic imbalances, or a sudden change in environment.

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Naxlex Comprehensive Predictor Exams

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Correct Answer is B

Explanation

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

Correct Answer is D

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?