The nurse is caring for a client who is post-op day 1 from a laparoscopic cholecystectomy.
Which task should the nurse delegate to the unlicensed assistive personnel?
Reassess the incision site for bleeding.
Increase the client's IV fluids.
Administer p.o. pain medication.
Assist the client to the bathroom.
The Correct Answer is D
Choice A rationale:
Reassess the incision site for bleeding. This task requires clinical judgment and should be performed by the nurse.
Choice B rationale:
Increase the client’s IV fluids. This task involves medication administration and should be performed by the nurse.
Choice C rationale:
Administer p.o. pain medication. This task involves medication administration and should be performed by the nurse.
Choice D rationale:
Assist the client to the bathroom. This is a task that can be safely delegated to unlicensed assistive personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sleeping too many hours can indeed cause fatigue. However, this is not the most likely cause in this case as the patient has fibromyalgia, which is often associated with sleep disturbances.
Choice B rationale:
While a new mattress might improve sleep quality, there’s no information suggesting that the patient’s mattress is a problem.
Choice C rationale:
Using electronics at bedtime can interfere with sleep, but again, there’s no information suggesting that this is the case here.
Choice D rationale:
Fibromyalgia is often associated with sleep disturbances such as insomnia. This is the most likely cause of the patient’s fatigue.
Choice E rationale:
Worrying can indeed cause fatigue, but there’s no information suggesting that the patient has been worried about anything in particular.
Correct Answer is ["C","D"]
Explanation
Choice A rationale:
Hypoglycemia is a condition characterized by low blood sugar levels. However, the client is on Prednisone and NSAIDs, which do not typically cause hypoglycemia. Therefore, it’s unlikely that the client would develop this condition as a side effect of these medications.
Choice B rationale:
Weight loss could occur in some individuals taking Prednisone due to potential side effects like loss of appetite or stomach upset. However, it’s more common for individuals on Prednisone to experience weight gain due to increased appetite.
Choice C rationale:
Weight gain is a common side effect of Prednisone. This medication can cause increased appetite leading to weight gain. It can also cause fluid retention and redistribution of fat, particularly in the face, back of the neck, and abdomen.
Choice D rationale:
Hyperglycemia, or high blood sugar, is a potential side effect of Prednisone. This medication can cause an increase in blood sugar levels, which if persistently high, can lead to diabetes. Regular monitoring of blood glucose levels is recommended for clients on this medication.
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