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 A
Explanation
Choice A rationale
Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.
Choice B rationale
Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.
Choice C rationale
While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.
Choice D rationale
Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale
Lamb’s wool is typically used for padding to prevent pressure sores and does not directly relate to the administration of oxygen therapy. Therefore, it is not necessary when a patient is put on oxygen.
Choice B rationale
Sterile water is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice C rationale
Tape can be used to secure the oxygen delivery device, such as a nasal cannula, to the patient’s face. Therefore, it is necessary when a patient is put on oxygen.
Choice D rationale
A suction canister is used to collect respiratory secretions during suctioning procedures, which may be necessary for patients with excessive secretions or difficulty clearing secretions.
Therefore, it is necessary when a patient is put on oxygen.
Choice E rationale
A humidifier bottle is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice F rationale
A nasal cannula is a device used to deliver supplemental oxygen to a patient who needs oxygen therapy. Therefore, it is necessary when a patient is put on oxygen.
Choice G rationale
A flowmeter is used in oxygen therapy to control the rate of oxygen flow to the patient. Therefore, it is necessary when a patient is put on oxygen.
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