A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

Tell the AP to list the steps of the task.

Instruct the AP to report back once the task is complete.

Ask the family if the AP performed the task correctly.

Request the AP to provide a return demonstration of the task.

Answer and Explanation

The Correct Answer is D

A. Telling the AP to list the steps of the task is not sufficient to ensure correct performance. It may show knowledge of the steps, but it does not ensure the AP is performing the task correctly or safely.

B. Instructing the AP to report back once the task is complete does not allow the nurse to actively observe the AP’s technique or provide feedback on performance.

C. Asking the family if the AP performed the task correctly may provide subjective input, but the nurse is responsible for assessing and ensuring the proper completion of nursing tasks.

D. Requesting the AP to provide a return demonstration of the task is the best method. This allows the nurse to directly observe the AP’s technique, correct any errors, and ensure that the task is performed according to the prescribed standards. This also serves as a valuable teaching opportunity.

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Correct Answer is B

Explanation

A. You wish you were no longer alive?: This response might sound accusatory and may invalidate the client's feelings. The nurse should express empathy and understanding instead of making the client feel misunderstood.

B. "It is common for people who have a terminal illness to feel that way.": This response validates the client's feelings by acknowledging the emotional distress that often accompanies a terminal illness. It normalizes the experience without minimizing it and opens the door for further discussion.

C. "Why do you wish you weren't alive any longer?": While this response is direct, it might sound too probing and may feel intrusive or dismissive of the client's emotional state. A softer, more empathetic approach is usually preferred.

D. "We should talk about the treatment plan your provider has suggested.": While discussing treatment plans is important, this response may deflect the client's emotional distress and shift the focus away from their immediate emotional needs. The nurse should first address the emotional aspect before discussing treatment.

A. Respiratory rate 16/min B. Blood pressure 110/70 mm Hg C. 400 mL of drainage in the collection chamber within 4 hr D. Fluctuation in the water seal chamber with respiration

Correct Answer is C

Explanation

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

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A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a terminal illness. The client states, "I wish I would die now." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Correct Answer is C

Explanation

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