The practical nurse (PN) reorients a male client to the correct time, day, date, location, and why he is here today but he is only able to remember his name and where he is. Based on these findings, what should the PN document?
Oriented x 3.
Oriented x 1.
Oriented x 2.
Oriented x 4.
The Correct Answer is C
A. Oriented x 3. - The client must recall the time, day, date, location, and reason for being there to be considered oriented x 3. As the client can only remember his name and location, it does not fulfill the criteria for oriented x 3.
B. Oriented x 1. - This is inaccurate as the patient is oriented in two aspects: person and place.
C. Oriented x 2. - The client recalls their name and place, hence is oriented in two aspects. This is therefore accurate.
D. Oriented x 4. - This would require the client to recall all four aspects of orientation (time, day, date, location, and reason for being there), which the client did not demonstrate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.
B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.
C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.
D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.
Correct Answer is B
Explanation
A. Cleansing the site and covering with a sterile towel is typically done by the healthcare provider performing the procedure.
B. Gathering the procedure tray and equipment ensures everything necessary for the thoracentesis is ready.
C. Placing the client in an orthopneic position may be part of the positioning during the procedure but is not the primary preparation.
D. Keeping the client NPO and encouraging voiding might be necessary for some procedures but isn't specific to thoracentesis preparation.
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