During the initial home visit, the nurse informs the client that the visits are expected to last for 6 weeks. Which phase of the helping relationship is the nurse in with this client?

Working phase

Pre-interaction phase

Orientation phase

Termination phase

Answer and Explanation

The Correct Answer is C

A. Working phase: The working phase occurs after the nurse and client have established trust and rapport, and the nurse begins actively implementing interventions, addressing problems, and facilitating behavior change. Discussing the expected duration of visits is part of relationship initiation rather than active intervention.

B. Pre-interaction phase: The pre-interaction phase occurs before the nurse meets the client, involving gathering data from records, planning care, and self-preparation. Since the nurse is already visiting the client and providing information directly, the pre-interaction phase has already passed.

C. Orientation phase: The orientation phase involves establishing rapport, clarifying roles, setting expectations, and defining the purpose and duration of the nurse-client relationship. By informing the client that visits are expected to last six weeks, the nurse is engaging in the orientation process, setting boundaries, and preparing the client for collaborative care.

D. Termination phase: The termination phase occurs at the end of the helping relationship, when goals have been achieved or the planned care period is concluding. Since this is the initial visit and the nurse is introducing the schedule of visits, the termination phase has not yet begun

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Correct Answer is D

Explanation

A. Administer a PRN inhaler medication and auscultate breath sounds: The immediate priority in this situation is to correct hypoxemia. Auscultation and PRN medication administration are important but secondary to ensuring adequate oxygenation, as oxygen saturation of 86% indicates severe hypoxemia that requires rapid intervention.

B. Immediately notify the provider of the client's oxygenation status: Notifying the provider is important for collaborative management, but the nurse’s first action must address the urgent physiologic threat—low oxygen saturation. Waiting for instructions without intervening could further compromise tissue oxygenation.

C. Titrate the oxygen down to 3 liters and closely monitor the client's response: Reducing oxygen in a patient with worsening hypoxemia could exacerbate oxygen deprivation. Although COPD patients are at risk for CO₂ retention, the immediate concern is life-threatening hypoxemia, and decreasing oxygen would be unsafe.

D. Titrate the oxygen up to 5 liters and closely monitor the client's response: Increasing supplemental oxygen is the immediate priority to raise oxygen saturation and prevent hypoxic injury. Titrating carefully while monitoring ensures that oxygenation improves without unnecessarily exceeding safe limits for a patient with COPD, balancing hypoxemia correction and risk of CO₂ retention.

A. Right direction B. Right person C. Right Supervision D. Right circumstance

Correct Answer is A

Explanation

A. Right direction: The RN clearly communicates the task (obtain a blood sugar), the specific parameters for reporting results (if below 70 or above 300), and important patient-specific instructions (use the left arm due to dialysis access). This precise instruction exemplifies the right direction, ensuring the UAP understands what is expected and when to notify the RN.

B. Right person: While assigning the task to a UAP implies consideration of the appropriate staff member, the scenario does not provide details about the UAP’s competence, experience, or scope of practice. Therefore, the right person is not explicitly verified in this step.

C. Right supervision: Supervision involves the RN monitoring, evaluating, and providing guidance throughout or after task completion. In this case, the RN only instructs the UAP and specifies reporting criteria but does not describe ongoing supervision, this right is not fully addressed.

D. Right circumstance: The right circumstance involves considering patient stability, complexity of care, and context of the work environment. While the instruction accounts for a dialysis access site, the overall patient condition and risk factors are not fully addressed in this step, the right circumstance is only partially considered.

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During the initial home visit, the nurse informs the client that the visits are expected to last for 6 weeks. Which phase of the helping relationship is the nurse in with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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