Which task could the RN delegate to the unlicensed assistive personnel (UAP)?

Irrigate the NG tube with water that is connected to suction for a post-operative client

Assist a client to the bathroom following administration of a soapsuds enema

Perform digital removal of stool on a client who is constipated

Check the tube feeding aspirate for pH and auscultate for bowel sounds

Answer and Explanation

The Correct Answer is B

Choice A reason: Irrigating an NG tube requires sterile technique and assessment of patency, which are beyond the UAP’s scope. This task involves clinical judgment to avoid complications like aspiration, making it inappropriate for delegation.

Choice B reason: Assisting a client to the bathroom post-enema is within the UAP’s scope, involving mobility support and safety. This task does not require clinical judgment beyond ensuring the client’s stability, making it appropriate for delegation.

Choice C reason: Digital removal of stool is an invasive procedure requiring assessment for complications like vagal stimulation or rectal trauma. It is outside the UAP’s scope, as it demands nursing judgment and skill.

Choice D reason: Checking tube feeding aspirate pH and auscultating bowel sounds involve clinical assessment to confirm tube placement and gastrointestinal function. These tasks require nursing expertise and cannot be delegated to a UAP.

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Correct Answer is B

Explanation

Choice A reason: Stopping the enema entirely is premature and unnecessary for cramping, which is a common response to rapid fluid instillation. Documentation of intolerance is only appropriate if the procedure cannot be completed after attempting adjustments. This action fails to address the cramping’s cause, potentially delaying constipation relief and patient comfort.

Choice B reason: Lowering the solution container reduces the flow rate of the enema, decreasing intraluminal pressure in the colon. Cramping often results from rapid fluid instillation stretching the bowel. Slowing the flow allows the colon to accommodate the fluid, alleviating discomfort while continuing the procedure effectively.

Choice C reason: Encouraging the client to bear down is inappropriate as it may cause premature expulsion of the enema fluid, reducing its effectiveness in relieving constipation. Bearing down increases intra-abdominal pressure, potentially exacerbating cramping rather than alleviating it, and does not address the underlying cause of discomfort from fluid instillation.

Choice D reason: Allowing the client to expel fluid prematurely interrupts the enema’s purpose of softening stool and stimulating bowel movement. While it may temporarily relieve cramping, it reduces the procedure’s efficacy, potentially requiring a repeat enema, which increases patient discomfort and procedural risks like rectal irritation.

A. 1.5 tablets B. 2.5 tablets C. 2 tablets D. 1 tablet

Correct Answer is A

Explanation

Choice A reason: Furosemide 60 mg requires 1.5 tablets of 40 mg (60 ÷ 40 = 1.5). Scored tablets allow precise division, ensuring the correct dose. This calculation aligns with safe medication administration principles, delivering the prescribed amount accurately.

Choice B reason: Administering 2.5 tablets (100 mg) exceeds the prescribed 60 mg dose. Overdosing furosemide, a loop diuretic, risks excessive diuresis, leading to dehydration, hypokalemia, or hypotension, making this choice unsafe and incorrect.

Choice C reason: Two tablets (80 mg) also exceed the 60 mg order. This overdose could cause significant fluid and electrolyte imbalances, particularly in vulnerable patients, as furosemide promotes rapid sodium and water excretion, making this choice inappropriate.

Choice D reason: One tablet (40 mg) underdoses the patient, providing only 66.7% of the prescribed 60 mg. Inadequate dosing may fail to achieve therapeutic effects, such as edema reduction or blood pressure control, rendering this choice incorrect.

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Which task could the RN delegate to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

Physician order reads: Furosemide 60 mg po bid. Available: 40 mg scored tablets. What do you administer to the patient?

Correct Answer is A

Explanation

There are a variety of medications that are commonly used to promote healthy bowel elimination. Which best describes a bulk-forming agent?

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Which task could the RN delegate to the unlicensed assistive personnel (UAP)?

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A nurse is planning care for a client admitted with diarrhea. Which of the following interventions would be a priority for this client?

A nurse working in a hospital included abdominal assessment as part of patient assessment. In which patient would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes?

The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?