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

Answer and Explanation

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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Correct Answer is A

Explanation

a. "You feel that your mother does not want you to come back home?" This response uses reflection, a therapeutic communication technique, to encourage the client to express and explore their feelings further.
b. "It's quite common for clients to feel that way after a lengthy hospitalization." While this normalizes the client's feelings, it might dismiss the client's unique emotional experience and does not invite further exploration.
c. "Why don't you talk to your mother? You may find out she doesn't feel that way." This response provides a solution but does not address the client's current emotional state or encourage them to express their feelings.
d. "Your mother seems like an understanding person. I'll help you approach her." This response makes an assumption about the mother and shifts the focus away from the client’s feelings.

A. Reaction Formation B. Projection C. Sublimation D. Repression

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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