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 C
Explanation
a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.
Correct Answer is A
Explanation
a. Recovery from anorexia nervosa is a marathon, not a sprint. Setting small, achievable goals like understanding the importance of nutrition is crucial for initial progress.
b. Aiming for immediate, perfect dietary adherence is unrealistic and can be discouraging. Building healthy eating habits takes time and support.
c. Unrealistic weight gain goals can be demotivating and potentially harmful. Weight gain should be gradual and monitored by a healthcare professional.
d. A sudden high-calorie diet can be overwhelming for someone with a restricted eating pattern and could lead to gastrointestinal distress.
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