An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?
Report the incident to the family.
Request that the man get up and leave.
Exit the room and quietly close the door.
Ask when the nurse should return.
The Correct Answer is C
Choice A rationale:
Reporting the incident to the family is not the first action the PN should take in this situation. It may be appropriate to inform the family later if necessary, but immediate action is needed to address the boundaries being crossed in the client's room.
Choice B rationale:
Requesting that the man get up and leave is not the first action the PN should take. This situation involves delicate and sensitive issues, and the PN should prioritize the client's privacy, dignity, and emotional well-being.
Choice C rationale:
The most appropriate first action is for the PN to exit the room and quietly close the door. This action respects the client's privacy and allows the couple to have some space and time to compose themselves.
Choice D rationale:
Asking when the nurse should return is not the first action to take. The PN needs to ensure the client's privacy and deal with the situation at hand discreetly. Later, the PN can discuss the incident with the client if necessary, or involve the appropriate authorities as per the facility's policy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A:
The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:
The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.
Choice B rationale:
This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.
Choice C rationale:
This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.
Choice D rationale:
This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.
Correct Answer is D
Explanation
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
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