The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?
Determine which foods aggravate the client's symptoms.
Elevate the head of the bed before the client begins to eat.
Teach the client about the need to eat small, frequent meals.
Assess the client for heartburn or a feeling of fullness after eating.
The Correct Answer is B
Choice A rationale: Determining which foods aggravate the client's symptoms is beyond the scope of the UAP and should be addressed by licensed healthcare providers. Choice B rationale: Elevating the head of the bed before the client begins to eat helps prevent reflux in clients with hiatal hernia, and it's a task that can be delegated to the UAP.
Choice C rationale: Teaching the client about the need to eat small, frequent meals is a nursing responsibility and should be performed by a licensed nurse.
Choice D rationale: Assessing the client for heartburn or a feeling of fullness after eating is a nursing responsibility and requires a licensed nurse's judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.
Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.
Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.
Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.
Correct Answer is C
Explanation
Choice A rationale: The initial administration of the opioid analgesic is appropriate as long as the nurse adheres to the prescription made.
Choice B rationale: Administering naloxone via IV is an appropriate intervention to reverse the effects of opioid toxicity. It is not the focus of counseling in this scenario.
Choice C rationale: The nurse should have notified the healthcare provider as soon as the client's respiratory rate decreased to 6 breaths/minute, which is a sign of respiratory depression caused by the opioid analgesic. The nurse should not have waited until the client's respiratory rate decreased to 4 breaths/minute, which is a life-threatening condition that requires immediate intervention.
Choice D rationale: Documentation of the client's respiratory rate is essential for monitoring, and there is no indication that the documentation was inappropriate.
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