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 B

Explanation

A. Periodic sighing and shaking the head: These may be signs of frustration but are less urgent compared to more severe behaviors.
B. Argumentativeness and use of profanity: These behaviors indicate increased agitation and potential for escalation. Monitoring these behaviors is crucial to de-escalate the situation and ensure safety.
C. Decreased activity level and change in affect: While important to monitor for changes in mood, these are less immediately concerning compared to signs of escalating agitation.
D. Repeated requests for attention from the nurse: This behavior indicates a need for attention but is less concerning compared to potentially aggressive or escalating behaviors.

A. Metabolic alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Respiratory alkalosis.

Correct Answer is D

Explanation

A. Metabolic alkalosis: This condition is typically caused by an increase in bicarbonate or a loss of hydrogen ions, often due to vomiting or excessive use of antacids. It is not commonly associated with hyperventilation.
B. Respiratory acidosis: This condition results from CO₂ retention due to inadequate ventilation, which is the opposite of hyperventilation. The adolescent’s hyperventilation indicates CO₂ loss rather than retention.
C. Metabolic acidosis: This condition is characterized by a decrease in bicarbonate or an increase in acid production, which does not align with the hyperventilation observed in this scenario.
D. Respiratory alkalosis: Hyperventilation leads to excessive CO₂ exhalation, causing a decrease in CO₂ levels in the blood and resulting in respiratory alkalosis. This is the expected acid-base imbalance due to the adolescent’s anxiety and hyperventilation.

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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

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

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Correct Answer is D

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