During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Assess her feelings about therapeutic abortions in the event the infant has been affected.

Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.

Instruct her to avoid sexual intercourse while active, visible lesions are present.

Determine if the client has taken acyclovir for this outbreak of genital herpes.

Answer and Explanation

The Correct Answer is C

A.   Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B.   Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C.   Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D.   Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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Correct Answer is B

Explanation

A. Requesting that the man leave violates the patient's right to privacy and intimacy.
B. In this situation, the practical nurse (PN) shouldexit the room and quietly close the door. This approach respects the privacy and dignity of the older female client and her male friend while maintaining professionalism and discretion. It avoids embarrassing or shaming the couple and allows them their personal space.
C. Asking when the nurse should return doesn't handle the immediate situation effectively.
D. Reporting the incident to the family might be an option, but the immediate action is to maintain appropriate boundaries by asking the man to leave.

A. Evaluate the client's understanding of discharge instructions following a colonoscopy. B. Encourage an elderly client who was admitted for dehydration to increase intake of oral fluids. C. Measure the urinary output of a client who is receiving diuretics for congestive heart failure. D. Check a client's femoral dressing for signs of bleeding after a cardiac catheterization.

Correct Answer is C

Explanation

A. Evaluating a client's understanding of discharge instructions typically requires a nursing assessment and explanation, more suitable for a licensed nurse.
B. Encouraging fluid intake might involve assessing the client's condition and providing specific advice, which aligns more with the responsibilities of a licensed nurse.
C. Measuring urinary output is a task that falls within the scope of practice for unlicensed assistive personnel (UAP), as it involves routine data collection and does not require clinical judgment.
D. Checking a client's femoral dressing after a cardiac catheterization requires observation for signs of bleeding, which involves assessment and potential interventions beyond the UAP's scope of practice.

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During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 room to administer medications and finds the couple in bed together. What action should the PN take?

Correct Answer is B

Explanation

Which assignment is best for the practical nurse to assign to the unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?

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The practical nurse (PN) is caring for a client newly diagnosed with diabetes mellitus. Which finding indicates that the PN should obtain a capillary glucose measurement to assess for hypoglycemia?

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