Two adult residents in the long-term care facility have developed an attraction for one another. The nursing assistant discovers them in a room engaging in sexual activity. What should the nursing assistant do?
A. Interrupt the sexual activity and separate the two residents.
B. Leave the room quietly and knock before entering the room next time.
C. Report the situation to the supervising nurse at once.
D. Call the families of each of the residents involved and explain what has happened.
Answer: B
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A woman in the third trimester of her first pregnancy complains of excessive fatigue. Her hemoglobin is 11.2 g/dL. What action by the nurse is best?
A. Arrange hospital admission for blood transfusions. B. Assess the woman's diet for adequate iron and protein. C. Inform the woman that this is a normal finding in pregnancy. D. Tell the woman to get more sleep at night and to take naps.
The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration. Which of the following findings are consistent with this condition? Standard Text: Select all that apply
1. Tenting noted on dorsal aspect of client's hand when skin turgor was assessed. 2. Client has produced 175 milliliters over the last 8 hours. 3. Dentures are loose, small sores noted in oral mucosa. 4. Healthcare provider notes client exhibiting xerostomia. 5. Client's apical heart rate is 82 beats per minute.
The health status of an older patient with liver disease is rapidly deteriorating. There is no documentation on the medical record regarding the patient's care wishes. What should the nurse do to ensure the patient receives care that is desired at the end of life?
1. Ask social services to provide an advance directive for the patient to complete. 2. Talk with the patient regarding what the patient wants after the hospitalization ends. 3. Call a meeting with the patient, family, and primary care physician to discuss care goals. 4. Discuss the patient's dire situation with the family and find out what their wishes might be.
The nurse is assigning an unlicensed assistive personnel (UAP) to work with a client who has a hearing aid. Which action by the UAP is inconsistent with appropriate delegation? The nurse asks the UAP to
a. cleanse the ear mold if needed with mild soap and water. b. evaluate how well the client understood the nurse's earlier instructions. c. help the client insert the ear mold into the ear. d. turn the hearing aid off before removing it at bedtime.