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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Related Questions
Correct Answer is C
Explanation
a. Reaction Formation: Reaction formation involves expressing the opposite of what one truly feels. Exploring a career that involves controlled expression of anger (such as professional wrestling) can be seen as a reaction formation against uncontrolled anger.
b. Projection: Projection involves attributing one's own unacceptable feelings or thoughts to others. Exploring a career in professional wrestling does not involve projecting one's own feelings onto others.
c. Sublimation: This is correct because sublimation involves channeling unacceptable impulses into socially acceptable activities. Exploring a career in professional wrestling could be seen as channeling anger into a constructive and socially acceptable outlet.
d. Repression: Repression involves pushing unacceptable thoughts or memories out of consciousness. Exploring a career in professional wrestling does not involve repressing anger but rather finding a way to express it constructively.
Correct Answer is D
Explanation
a. "I'm afraid you would feel very guilty leaving your parents." This response assumes a negative outcome and does not encourage independent decision-making.
b. "Why would you want to leave a secure home?" This response discourages the client from considering independence and reinforces dependent behavior.
c. "It would be best to do that to increase independence." This statement provides advice rather than encouraging the client to explore their own feelings and options.
d. "Let's discuss and explore all of your options." This is correct because it encourages the client to consider various possibilities and promotes independent decision-making, which is essential for someone with dependent behaviors.
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