Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?
Ignore the behavior and proceed with the IV antibiotic administration.
Instruct the patient to cease the inappropriate behavior.
Exit the room and close the door quietly.
Fill out an unusual occurrence report.
The Correct Answer is C
Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.80"]
Explanation
Step 1 is to convert the patient’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.20462 pounds. So, the patient’s weight in kilograms is 132 pounds ÷ 2.20462 = 59.87 kg.
Step 2 is to calculate the total dosage of dantrolene needed. The prescribed dosage is 1.5 mg/kg. So, the total dosage is 1.5 mg/kg × 59.87 kg = 89.81 mg.
Step 3 is to calculate the volume of reconstituted dantrolene solution needed to provide the total dosage. The reconstituted solution has a concentration of 50 mg/mL. So, the volume needed is 89.81 mg ÷ 50 mg/mL = 1.80 mL.
Correct Answer is B
Explanation
Choice A rationale
While regular monitoring of blood sugar levels is important in managing diabetes, checking every four to six hours every day may not be necessary for all patients. The frequency of blood glucose monitoring should be individualized based on the type and severity of the diabetes, the patient’s blood glucose control, and the patient’s specific needs.
Choice B rationale
Keeping diabetic medication on schedule as prescribed is crucial in managing blood glucose levels and preventing complications related to diabetes. This indicates that the patient has understood the importance of medication adherence in diabetes management.
Choice C rationale
While it’s recommended to limit alcohol consumption, restricting alcoholic beverages to no more than 1-2 per week is not a standard guideline for all patients with diabetes. The effects of alcohol on blood glucose levels can vary depending on several factors, including the amount of alcohol consumed, the presence of food, and the individual’s overall diabetes management.
Choice D rationale
Limiting daily fat intake to 15% of total calories is not a standard recommendation for patients with diabetes. The American Diabetes Association recommends individualized medical nutrition therapy to manage diabetes, which may include monitoring carbohydrate intake and considering the quality of fats and proteins in the diet.
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