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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Initiating a hearing and vision screening program for first graders is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage, which is exactly what a screening program does.

Choice B rationale
Observing a person with type I diabetes mellitus self-administer a dose of insulin is not an example of secondary prevention. This is more related to disease management, which falls under tertiary prevention.

Choice C rationale
Preparing a presentation on how to prevent the spread of lice is an example of primary prevention, which aims to prevent disease or injury before it ever occurs.

Choice D rationale
Collaborating with a science teacher to prepare a health lesson could be seen as primary prevention if the lesson is about preventing disease, or tertiary prevention if it’s about managing existing conditions.

A. Stabilize the cervical spine. B. Check for a pulse. C. Request an x-ray. D. Assess the respiratory rate. E. Examine the abdomen. F. Ensure the airway is patent.

Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What action should the school nurse take to provide secondary prevention for school-aged children?

Correct Answer is A

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

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The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

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?