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 D
Explanation
a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.
Correct Answer is A
Explanation
a. fluoxetine: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been used with some success in treating anorexia nervosa, especially when comorbid with depression. It can help with mood stabilization and reducing obsessive-compulsive behaviors related to food.
b. sibutramine: Sibutramine was an appetite suppressant used for weight loss, but it has been withdrawn from the market in many countries due to cardiovascular risks. It is not used for treating anorexia nervosa.
c. carbamazepine; Carbamazepine is an anticonvulsant and mood stabilizer, primarily used for bipolar disorder and seizure disorders. It is not commonly used for anorexia nervosa.
d. diazepam: Diazepam is a benzodiazepine used primarily for anxiety, muscle spasms, and seizures. It does not have a primary role in the treatment of anorexia nervosa and depression.
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