the client requests to get out of bed to go bathroom. he has orders for "up ad lib". what action do you take?
1.tell him its not good idea and provide urinal
2. ask for the nursing assistant to assist him to the bathroom
3. give him some slippers, and tell him where the bathroom is located.
my answer: [color=#b22222]thinking that up ad lib means the pt can do as much exercise he wants i choose answer number 3.
the correct answer is number 2
i can help with this one. this is a classic example of your needing to think beyond the details of the question to why they ask you this.
1) obviously, if the patient is able to get up ad lib, telling him no and giving him a urinal is making him more dependent than he needs to be. we never make people more dependent on help, equipment, or whatever, if they don't need it. so that's out, and that's why.
3) this question does not tell you how long this patient has been in your care, or anything else. this might be his first attempt to get out of bed, or he might be confused, or he might need supervision for another reason. you do not know any of this, so just giving him his slippers and turning him loose makes your nursing supervision of him less effective. so this is not the best answer-- it does not inform the questioner on whether or not you have assessed him for safety or that it even occurred to you to care.
2) now, i know that we don't always think of turfing tasks off to the cna. however, given these three choices, and the rationales for why the other two are not acceptable, perhaps you can see that as you, the nurse, do not know how he'll be on his feet or whether he'll do the right thing when he's on them, and knowing that you can delegate this level of supervision to a cna, it is most appropriate for you to do that delegation so he will be supervised and if anything untoward happens she will report it to you.
nursing school is to teach you to think like a nurse... and although we might not like the three choices you have here, that doesn't matter. here they are. this is why the answer is, in fact, 2. it asks for a higher level of nursing judgment.
#1 - there are no "what ifs" in the world of NCLEX testing - all you know is what the question states. Your challenge is to choose the BEST answer, not what you would do in the "real world" of nursing. Acting out of concern for patient safety is always the "best" answer :)
"Requests to get out of bed" is your clue in the stem. It indicates that while his order is up ad lib, he may need assistance. In the real world, you'll find that many times perfectly able bodied patients need help or that you help them up regardless. People in a hospital bed, for whatever reason, pretty much across the board could use and appreciate a helping hand. It promotes safety and conveys caring.
I like to use the power of imagination and make verbalize the answers to questions as responses by the me as the nurse. The patient says "Nurse, I'd like to get out of bed and go to the bathroom". Now what response by you would show you care about the patient and you are concerned for his safety (two strategies which work 99% of the time)
1. "Sir, getting out of bed is not a good idea. Here is a urinal."
2. "Sir, let me get Beth, the CNA, and she will help you to the bathroom."
3. "Sir, here are your slippers. The bathroom is over there."
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
the client requests to get out of bed to go bathroom. he has orders for "up ad lib". what action do you take?
1.tell him its not good idea and provide urinal
2. ask for the nursing assistant to assist him to the bathroom
3. give him some slippers, and tell him where the bathroom is located.
my answer: [color=#b22222]thinking that up ad lib means the pt can do as much exercise he wants i choose answer number 3.
the correct answer is number 2
i can help with this one. this is a classic example of your needing to think beyond the details of the question to why they ask you this.
1) obviously, if the patient is able to get up ad lib, telling him no and giving him a urinal is making him more dependent than he needs to be. we never make people more dependent on help, equipment, or whatever, if they don't need it. so that's out, and that's why.
3) this question does not tell you how long this patient has been in your care, or anything else. this might be his first attempt to get out of bed, or he might be confused, or he might need supervision for another reason. you do not know any of this, so just giving him his slippers and turning him loose makes your nursing supervision of him less effective. so this is not the best answer-- it does not inform the questioner on whether or not you have assessed him for safety or that it even occurred to you to care.
2) now, i know that we don't always think of turfing tasks off to the cna. however, given these three choices, and the rationales for why the other two are not acceptable, perhaps you can see that as you, the nurse, do not know how he'll be on his feet or whether he'll do the right thing when he's on them, and knowing that you can delegate this level of supervision to a cna, it is most appropriate for you to do that delegation so he will be supervised and if anything untoward happens she will report it to you.
nursing school is to teach you to think like a nurse... and although we might not like the three choices you have here, that doesn't matter. here they are. this is why the answer is, in fact, 2. it asks for a higher level of nursing judgment.