The practical nurse (PN) is checking residual volume prior to the administration of a bolus feeding to a client with a percutaneous endoscopic gastrostomy (PEG) tube when the unlicensed assistive personnel (UAP) reports that another client has requested pain medication for postoperative pain. Which action should the PN take?
Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in progress.
Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic.
Tell the UAP that the client's pain will subside when the client is not disturbed and is allowed uninterrupted rest.
Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client.
The Correct Answer is A
A. Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in progress:
Pain assessment and medication administration require licensed personnel. The PN should finish the current task and promptly address the client in pain.
B. Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic:
UAPs cannot administer tube feedings unless trained and delegated appropriately, and in most settings, PEG bolus feeding is the PN’s responsibility.
C. Tell the UAP that the client's pain will subside when the client is not disturbed:
Ignoring or delaying pain relief is inappropriate and unethical.
D. Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client:
Measuring gastric residual requires clinical judgment and is a PN responsibility, not a UAP task.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Restrict family visitation: Family support may help anxiety; restriction is not helpful.
B. Administer PRN opioid analgesic: Opioids relieve pain and dyspnea in palliative care, improving comfort.
C. Apply a non-rebreather mask: Not appropriate for chronic CO₂ retainers; could worsen hypercapnia.
D. Place client in high Fowler's position: Helps breathing but does not address pain; could be done after pain relief.
Correct Answer is D
Explanation
A. The child will no longer be contagious, no need to take any further precautions:
RSV remains contagious for days to weeks after symptoms begin.
B. Make sure there are no children under the age of 6 months around the infected child:
Although infants are more vulnerable, all children are at risk - restriction should apply to everyone.
C. The child can be around other children but should wear a mask at all times:
Masks are not fully effective in preventing RSV spread, especially in very young children.
D. Do not expose other children as the virus is very contagious even without direct oral contact:
RSV spreads through respiratory droplets and contaminated surfaces.
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