Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
Instruct the UAP to ask the visitor to get off the client's bed.
Discuss why visitors should not lie in the bed with the client.
Explain that the client has the right to have a visitor lie on the bed.
Notify the charge nurse that the visitor is lying on the client's bed.
The Correct Answer is C
Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.
Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.
Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.
Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.
Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.
Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.
Correct Answer is C
Explanation
Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.
Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.
Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.
Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.
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