Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?
Blood pressure of 144/84.
Oxygen saturation measurement of 95 to 96%.
Oriented to person only.
Urinary output of 50 mL/hour.
The Correct Answer is C
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
: 1
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD. Contact information for a women’s shelter.
Choice A rationale:
While providing a safety plan is important, it may not be the most immediate or practical resource for a client in an abusive situation. A safety plan is a detailed strategy for leaving an abusive relationship safely, but it requires time and preparation, which may not be feasible in an urgent situation.
Choice B rationale:
Paperwork for a restraining order is a legal step that can help protect the client, but it may not provide immediate safety. The process of obtaining a restraining order can take time, and the client may need immediate shelter and support.
Choice C rationale:
Documenting the report of abuse in the visit summary is important for medical and legal records, but it does not directly provide the client with immediate resources or safety. This documentation can be useful for future legal actions but does not address the client’s immediate need for safety and support.
Choice D rationale:
Providing contact information for a women’s shelter is the most appropriate response because it offers immediate safety and support. Women’s shelters provide a safe haven, counseling, legal support, and other resources necessary for individuals experiencing domestic violence.This option prioritizes the client’s immediate safety and well-being.
Correct Answer is D
Explanation
This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.
The other options are not correct because:
A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
