A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

Postpone ADLS until an occupational therapist determines the client's abilities.

Eliminate daily care that is not essential for the client's recovery.

Inform the client of the time the ADLS will be performed.

Determine the client's preferences.

Answer and Explanation

The Correct Answer is C

A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.

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Correct Answer is C

Explanation

A. Whole grain cereal: Not recommended. Whole grains can be high in insoluble fiber, which may worsen diarrhea.
B. Chocolate ice cream: Not recommended. Ice cream, especially chocolate-flavored, contains dairy and fat, which may exacerbate diarrhea.
C. Sliced bananas: Bananas are easy to digest, provide potassium, and can help firm up stools.
D. Hot coffee: Not recommended. Coffee is a stimulant and can irritate the gastrointestinal tract, potentially worsening diarrhea.

A. Draw up the formula into a syringe. B. Determine the pH level of gastric contents. C. Flush the nasogastric tube with 30 mL of water. D. Measure the total volume of gastric residual.

Correct Answer is B

Explanation

A. Draw up the formula into a syringe. This step is premature and should be done after confirming the tube placement and checking for residual volume.
B. Determine the pH level of gastric contents. Checking the pH level of gastric contents helps confirm the placement of the nasogastric tube in the stomach, which is crucial before administering feedings or medications to prevent aspiration.
C. Flush the nasogastric tube with 30 mL of water. Flushing is important but should be done after confirming tube placement.
D. Measure the total volume of gastric residual. Measuring residual volume is important but should be done after confirming tube placement.

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A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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