An adolescent client who recently lost most sight in both eyes has been admitted for evaluation. The nurse observes an unlicensed assistive personnel (UAP) who is assisting the client to walk in the hallway for the first time since admission, as seen in the picture. Which action should the nurse take?

Encourage the UAP to continue to assist the client down the hallway.

Demonstrate to the UAP how to assist the client with ambulation more safely.

Instruct the UAP to guide the client back to his room right away.

Advise the UAP to stay nearby but allow the client to ambulate independently.

Answer and Explanation

The Correct Answer is B

A.   While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B.   Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C.   This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D.   Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

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Correct Answer is A

Explanation

A. Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B. Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C. While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D. Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

A. Add the second portion of the feeding before the syringe is completely empty. B. Use 25 mL of water between the two portions of the feeding to flush the GT. C. Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D. Flush the tube with 50 mL of water between the two portions of the feeding.

Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

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Naxlex Comprehensive Predictor Exams

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

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The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

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