A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?
Tell the AP to list the steps of the task.
Instruct the AP to report back once the task is complete.
Ask the family if the AP performed the task correctly.
Request the AP to provide a return demonstration of the task.
The Correct Answer is D
A. Telling the AP to list the steps of the task is not sufficient to ensure correct performance. It may show knowledge of the steps, but it does not ensure the AP is performing the task correctly or safely.
B. Instructing the AP to report back once the task is complete does not allow the nurse to actively observe the AP’s technique or provide feedback on performance.
C. Asking the family if the AP performed the task correctly may provide subjective input, but the nurse is responsible for assessing and ensuring the proper completion of nursing tasks.
D. Requesting the AP to provide a return demonstration of the task is the best method. This allows the nurse to directly observe the AP’s technique, correct any errors, and ensure that the task is performed according to the prescribed standards. This also serves as a valuable teaching opportunity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "If I were you, I would contact your spiritual director.": While this may be a helpful suggestion for the client, it can come across as dismissive of the client’s personal beliefs and decision-making. The nurse should respect the client’s autonomy in making healthcare decisions.
B. "I'm sure that everything will be all right, regardless of your decision.": This statement may be dismissive of the client's concerns and the seriousness of their medical decision. It also minimizes the importance of the client’s decision, which should be respected.
C. "Making this decision is wrong.": This response is judgmental and violates the client’s autonomy. The nurse should avoid imposing personal beliefs and instead support the client’s choices.
D. "You have a right to change your mind.": This is the best response, as it acknowledges the client’s autonomy and the possibility that the client may reconsider their decision in the future. It provides a nonjudgmental and supportive statement that empowers the client.
Correct Answer is A
Explanation
A. Measure the client's abdominal girth daily is correct. Ascites is characterized by fluid accumulation in the abdomen. Measuring abdominal girth regularly is important for monitoring changes in the amount of fluid retention and for assessing the progression of ascites. It is a standard nursing intervention for clients with this condition.
B. Keep the client's daily protein intake below 0.8 g/kg is incorrect. Protein intake should not be restricted to this extent. In fact, adequate protein is important for liver health and to prevent muscle wasting in clients with cirrhosis, unless there are complications such as hepatic encephalopathy.
C. Restrict the client's sodium intake to 3 g per day is incorrect. Sodium intake is typically restricted more severely for clients with ascites. The general recommendation is often less than 2 g per day to help prevent fluid retention and reduce the burden on the heart and kidneys.
D. Position the client supine with legs elevated is incorrect. While elevating the legs can help reduce edema in the legs, positioning the client supine does not provide the same benefit for ascites. Side-lying with legs elevated or sitting with the legs elevated may be more beneficial.
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.