The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?
Listen to the breath sounds in all lung fields
Document the amount of output on the I & O sheet
Check the abdominal dressing for bleeding
Increase the IV fluid flow rate if the blood pressure is low
The Correct Answer is B
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.
b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.
c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.
d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.
e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.
Correct Answer is A
Explanation
a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.
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