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

Leave the room and close the door quietly.

Ignore the behavior and hang the IV antibiotic.

Complete an unusual occurrence report.

Tell the client to stop the inappropriate behavior.

Answer and Explanation

The Correct Answer is A

A.   Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B.   Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C.   Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D.   Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

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Correct Answer is C

Explanation

A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect

catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.

D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.

A. Apply a water-soluble lubricant to the catheter. B. Wear protective goggles while performing the procedure. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

Correct Answer is B

Explanation

A. Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B. Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C. Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D. Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

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

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Naxlex Comprehensive Predictor Exams

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