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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because symptoms are subjective or objective manifestations of a health problem that are perceived or reported by the client.
Choice B reason: This is incorrect because urinary retention is a specific condition that involves the inability to empty the bladder completely, which is not related to the data presented.
Choice C reason: This is incorrect because signs of fluid overload are opposite to the data presented, such as edema, weight gain, crackles in the lungs, and distended neck veins.
Choice D reason: This is incorrect because data clustering is a process of grouping related data together to identify paterns and potential problems, not a type of data itself.
Correct Answer is A
Explanation
Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.
Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.
Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.
Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.
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