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 A
Explanation
Choice A rationale: Conducting a closer examination of staff nurses' distribution of pain medication is the first step to identify any issues or patterns contributing to the higher than-usual administration of narcotic pain medications.
Choice B rationale: Holding a mandatory staff meeting may be necessary, but a focused examination should precede broader discussions.
Choice C rationale: Questioning clients about the effectiveness of pain medication is an important aspect of the investigation but should follow a thorough examination of medication distribution.
Choice D rationale: Discussing with the healthcare provider about changing client analgesia may be considered later based on the findings of the examination.
Correct Answer is B
Explanation
Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.
Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.
Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica
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