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 it shows that the nurse is engaged and focused on the patient. Leaning slightly forward indicates that the nurse is listening and caring.
Choice B reason: This is correct because it shows that the nurse is open and receptive to the patient’s feelings and concerns. An open posture means that the nurse does not cross arms or legs, which can be seen as defensive or closed.
Choice C reason: This is incorrect because it shows that the nurse is distant and distracted from the patient. Standing at the doorway implies that the nurse is ready to leave or has other priorities. Reading the chart while smiling may seem insincere or superficial.
Choice D reason: This is correct because it shows that the nurse is respectful and atentive to the patient. Sitting at the bedside and facing the patient indicates that the nurse is giving eye contact and acknowledging the patient’s
presence.
Correct Answer is B
Explanation
Choice A reason: "There is no reason to worry. This surgeon has an excellent reputation.” is not the best nursing response. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows authority, which is a communication barrier that involves using one’s position or status to influence or persuade the other person. It does not address the client’s emotions or needs, and may sound patronizing or condescending. Therefore, this choice is incorrect.
Choice B reason: “It sounds as though you have mixed feelings about the surgery. Can you tell me more about how you feel?” is the best nursing response. 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 emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.
Choice C reason: "The benefits outweigh the risks. You can be confident that the surgery should be done.” is not the best nursing response. This response shows persuasion, which is a communication technique that involves using logic or evidence to convince or influence 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 does not address the client’s emotions or needs, and may sound coercive or manipulative. Therefore, this choice is incorrect.
Choice D reason: "You are bound to feel much beter once it is all over with.” is not the best nursing response. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also shows avoidance, which is a communication barrier that involves shifting the focus away from the other person’s feelings or situation. It does not address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.
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