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 B

Explanation

a. decrease anxiety and ignore all the alternate personalities. Ignoring alternate personalities is not a therapeutic goal and could lead to further distress and fragmentation.
b. blend all the personalities into one. The primary goal of therapy for Dissociative Identity Disorder (DID) is often to integrate the separate identities into one cohesive identity, facilitating overall functioning and stability.
c. prevent social isolation: While preventing social isolation is important, it is not the primary therapeutic goal specific to DID.
d. forget the past trauma: The goal is not to forget the past trauma but to integrate and process traumatic memories in a healthy way, reducing the impact on the individual's functioning.

A. "Where do you buy your food?" B. "Does someone else prepare your meals?" C. "Tell me what you eat in a typical day. D. Are you taking any medications that change your taste of foods?"

Correct Answer is C

Explanation

a. "Where do you buy your food?" While this provides information about food access, it doesn’t directly assess nutritional intake.
b. "Does someone else prepare your meals?" This might provide insight into the client's independence, but it doesn't directly assess nutritional intake.
c. "Tell me what you eat in a typical day." This directly assesses the client’s dietary intake and provides a comprehensive view of their nutrition status.
d. "Are you taking any medications that change your taste of foods?" This is relevant but more specific to one aspect of dietary intake. It does not provide a full picture of the client’s nutritional status like option c.

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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

A client is diagnosed with Dissociative Identity Disorder. What would be the goal of therapy for this client? To:

Correct Answer is B

Explanation

The nurse is assessing an alert and independent older client for the risk of malnutrition. What item is most appropriate to assess?

Correct Answer is C

Explanation

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