A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Administer an enteral feeding to a client who has a new gastrostomy tube.

Measure the output from a client's indwelling urinary catheter.

Evaluate a client's pain level 30 min after receiving an oral analgesic.

Reinforce foot care to a client who has a new diagnosis of diabetes mellitus.

Answer and Explanation

The Correct Answer is B

Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.

The other tasks mentioned should not be delegated to an AP:

Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.

Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.

Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires

specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.

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Correct Answer is B

Explanation

Peptic ulcer disease is characterized by open sores that develop on the lining of the stomach, small intestine, or esophagus. The symptoms and pain associated with peptic ulcer disease can

vary, but certain patterns are commonly observed: "The pain is worse after I eat a meal high in fat": This statement aligns with the typical symptom of peptic ulcer disease. The presence of fat in the stomach triggers the release of certain hormones and substances that stimulate gastric acid secretion. This increased acid production can exacerbate the pain experienced by individuals with peptic ulcers.

"I feel so much better after eating": Feeling relief after eating is not characteristic of peptic ulcer disease. In fact, individuals with peptic ulcers may experience pain or discomfort after eating especially those with gastric ulcers.

"The pain radiates down to my lower back": Lower back pain is not a common symptom associated specifically with peptic ulcer disease. Radiating pain to the back is more commonly associated with conditions like pancreatitis or kidney issues.

"My pain is relieved by having a bowel movement": Pain relief with bowel movements is not a typical symptom of peptic ulcer disease. It may be more indicative of conditions like irritable bowel syndrome or inflammatory bowel disease.

A. To confirm the placement of the NG tube B. To determine the client's electrolyte balance C. To remove gastric acid that might cause dyspepsia D. To identify delayed gastric emptying

Correct Answer is D

Explanation

The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.

By measuring gastric residual, the nurse can:

● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.

● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.

● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.

Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.

While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.

Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.

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A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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