When entering a client's room to administer a 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Tell the client to stop the inappropriate behavior.

Ignore the behavior and hang the IV antibiotic.

Leave the room and close the door quietly.

Complete an unusual occurrence report.

Answer and Explanation

The Correct Answer is C

A. Telling the client to stop the behavior may be perceived as confrontational and unprofessional in a private setting. The focus should be on maintaining professionalism and patient privacy.
B. Ignoring the behavior is inappropriate as it does not address the situation or ensure the client's care needs are met. The nurse should handle the situation while maintaining professionalism.
C. Leaving the room and closing the door quietly is the most appropriate action. It respects the client's privacy while allowing the nurse to return to the room to provide care at an appropriate time.
D. Completing an unusual occurrence report is not necessary unless there is a safety issue or policy breach. The immediate concern is to handle the situation professionally and discreetly.

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Correct Answer is A

Explanation

A. Raising the head of the bed to 30 degrees with head and neck in neutral alignment helps to improve cerebral perfusion and facilitate the CT scan. This action is the immediate priority to prepare for the imaging study.
B. Administering aspirin is appropriate for stroke management, but it is not the first step before the CT scan, as the type of stroke needs to be determined first (ischemic vs. hemorrhagic).
C. Starting two large-bore IV catheters and reviewing criteria for IV fibrinolytic therapy is important for treatment but is not the immediate step before the CT scan. The CT scan needs to be performed to determine if thrombolytics are appropriate.
D. Continuous observation for neurologic dysfunction is important for ongoing care but does not address the immediate need to prepare for the CT scan.

A. Measure the child's height and weight B. Document lying, sitting, and standing blood pressures C. Locate and mark the pedal pulses D. Perform a mini mental exam on the child E. Obtain a history of allergic reactions F. Determine when the child last ate

Correct Answer is ["A","B","C","E","F"]

Explanation

A Measuring the child's height and weight is essential to ensure appropriate dosing of medications and to assess the child's growth and development.
B Documenting lying, sitting, and standing blood pressures can help detect orthostatic hypotension, which may be a concern during or after the procedure.
C Locating and marking the pedal pulses is important for assessing the vascular status of the lower extremities, especially since the catheterization involves accessing a blood vessel.
D Performing a mini mental exam on the child is not typically part of the pre-cardiac catheterization assessment for a 3-year-old.
E Obtaining a history of allergic reactions is crucial to prevent any potential allergic response to medications or materials used during the catheterization.
F Determining when the child last ate is necessary because the child will need to fast for a certain period before the procedure to reduce the risk of aspiration.

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When entering a client's room to administer a 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Correct Answer is ["A","B","C","E","F"]

Explanation

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