A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coffee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)
Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding
Stop administering the tube feeding and assist the client who spilled coffee with changing her wet clothing and
assess for burns
Request a replacement tray and assist the client with changing her wet clothing
Correct Answer : B
Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coffee. The nurse should not delay providing care for a client who may have suffered a burn.
Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coffee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.
Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coffee. The nurse should not focus on replacing the tray before assessing for burns.
Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coffee.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because placing soiled linens in the dirty linen receptacle can expose other clients and staff to the hepatitis virus, which can be transmited through blood and body fluids.
Choice B reason: This is incorrect because placing soiled linens on the floor can create a safety hazard and a potential source of infection for anyone who comes in contact with them.
Choice C reason: This is correct because placing soiled linens in a plastic bag that has the contamination symbol can prevent the spread of infection and alert the laundry department to handle them with caution.
Choice D reason: This is incorrect because placing soiled linens in the hazardous waste receptacle can waste resources and violate the regulations for disposing of hazardous materials.
Correct Answer is B
Explanation
Choice A reason: "Alcoholism is a disease that affects the whole family.” is not the best response to the client’s husband. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows lecturing, which is a communication barrier that involves giving unsolicited advice or information to the other person. It may make the client’s husband feel stereotyped, judged, or patronized, and may discourage further communication. Therefore, this choice is incorrect.
Choice B reason: "You sound frustrated in dealing with your wife’s drinking problem.” is the best response to the client’s husband. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s husband’s emotions, and invites him to express his concerns or fears. Therefore, this choice is correct.
Choice C reason: "I think you are a good person to stay here with your wife.” is not the best response to the client’s husband. This response shows praise, which is a communication technique that involves giving positive feedback or recognition to the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It may make the client’s husband feel uncomfortable, embarrassed, or pressured, and may not address his underlying feelings or needs. Therefore, this choice is incorrect.
Choice D reason: “Have you discussed this subject at the support group meetings?” is not the best response to the client’s husband. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows probing, which is a communication barrier that involves asking too many or inappropriate questions to the other person. It may make the client’s husband feel defensive, invaded, or resentful, and may violate his privacy or confidentiality. Therefore, this choice is incorrect.
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