The practical nurse (PN) enters the room of an older adult client. In preparation for transporting the client to the day room, the unlicensed assistive personnel (UAP) has positioned the client in a wheelchair. Which action by the PN takes priority?
Instruct the UAP in repositioning the urinary drainage bag.
Document the amount and appearance of the client's urine.
Offer to cover the client's arms and chest with the blanket.
Confirm with the client of being ready to go to the day room.
The Correct Answer is A
A. Instruct the UAP in repositioning the urinary drainage bag: The bag should be kept below the bladder level to prevent backflow and infection risk; positioning above the bladder is unsafe.
B. Document the amount and appearance of the client's urine: Important but not the first action when there’s an immediate risk of infection from improper drainage bag positioning.
C. Offer to cover the client's arms and chest with the blanket: Comfort is secondary to infection prevention and safety.
D. Confirm with the client of being ready to go to the day room: Communication is important but safety comes first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tell the nurse assigned to the client about the event so the findings can be recorded: The PN must first verbally report to the responsible nurse to ensure continuity of care and proper documentation.
B. Enter computer documentation of the findings and the application of a dressing: Documentation is essential but comes after notifying the primary nurse in charge of the client.
C. Inform the charge nurse that the findings indicate that the client pulled out the IV: Assumptions should be avoided unless confirmed; the PN should report only observed facts.
D. Complete the shift documentation for this client and include the findings about the IV: This delays immediate communication to the responsible nurse and could jeopardize timely care.
Correct Answer is D
Explanation
A. Nausea occurs at the onset of labor:
Nausea may occur but is not the primary reason for NPO status.
B. Emptying time of the stomach is increased in labor:
True, but the main concern is aspiration risk.
C. Blood is shunted from the gut during labor:
Not the major factor for NPO order.
D. There is increased risk of aspiration of emesis:
During labor, anesthesia may be required; delayed gastric emptying increases aspiration risk if vomiting occurs under sedation.
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