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","D","E"]
Explanation
Choice A rationale: Reducing the white blood cell count is not a goal of SIRS treatment, as it would impair the immune system's ability to fight the infection.
Choice B rationale: Maintaining body temperature within normal limits is a collaborative goal to address the signs of SIRS.
Choice C rationale: Decreasing blood pressure is not typically a goal in the management of SIRS; the focus is on maintaining adequate perfusion.
Choice D rationale: Achieving a negative urine culture is a collaborative goal to address the underlying urinary tract infection.
Choice E rationale: incision free of exudate is an indicator of resolving infection and inflammation.
Correct Answer is C
Explanation
Choice A rationale: The risk management nurse is not typically responsible for coordinating patient care through rehabilitation and discharge.
Choice B rationale: The neurology unit supervisor may have expertise in neurology care but may not be directly involved in coordinating care through rehabilitation and discharge.
Choice C rationale: The nurse case manager is specifically trained to coordinate and manage the care of patients through the entire healthcare continuum, including rehabilitation and discharge.
Choice D rationale: While the adult nurse practitioner may be involved in the patient's care, the nurse case manager is spec
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