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

After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.

While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.

Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.

A. Take the medication with an antacid B. Take the medication 1 hr before meals C. Take as needed for pain relief D. Store the medication in the refrigerator

Correct Answer is B

Explanation

Sucralfate is a medication commonly used in the treatment of peptic ulcer disease. It works by forming a protective barrier over the ulcer site, providing a physical barrier against gastric acid, and promoting the healing process. When teaching a client about sucralfate, it is important to provide instructions regarding its proper administration.

One of the key instructions is to take sucralfate 1 hour before meals. This timing allows the medication to form a protective coating in the stomach before food is ingested. Taking sucralfate on an empty stomach enhances its effectiveness in protecting the ulcer and promoting healing.

"Take the medication with an antacid" - Sucralfate should not be taken with an antacid. Antacids can interfere with the protective mechanism of sucralfate by neutralizing stomach acid, which is necessary for sucralfate to bind and form a protective coating. It is recommended to wait at least 30 minutes to 1 hour after taking sucralfate before taking an antacid.

"Take as needed for pain relief" - Sucralfate is not typically used for immediate pain relief in peptic ulcer disease. It is primarily used for its protective and healing properties. Pain relief is

usually addressed with other medications, such as antacids, acid-reducing medications, or pain medications as prescribed by a healthcare provider.

"Store the medication in the refrigerator" - Sucralfate does not require refrigeration. It should be stored at room temperature, away from excessive heat or moisture, as per the specific instructions provided by the manufacturer or healthcare provider.

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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 caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is checking the client's bowel sounds. At which time should the nurse auscultate the client's abdomen?

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1000 mL to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

A nurse is caring for a client who is taking cimetidine. Which of the following client statements indicates to the nurse that the cimetidine treatment has been effective? (Select all that apply.)

A nurse is reinforcing teaching with a client who reports taking bisacodyl daily. Which of the following information should the nurse include?

A nurse is caring for a client who is taking furosemide. For which of the following adverse effects should the nurse monitor?

A nurse is reinforcing teaching with a client who has a duodenal ulcer and has a new prescription for sucralfate. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?