A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

Ask the client's closest kin to convince him to stop fasting due to his injuries.

Encourage the client to stop fasting, as it will delay the wound healing process.

Call dietary to reschedule the client's meals.

Start enteral tube feedings if the client refuses to take food orally.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.

Choice B rationale:

Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.

Choice C rationale:

Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.

Choice D rationale:

Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.

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Correct Answer is B

Explanation

Choice A rationale:

Asthma - Asthma is a chronic respiratory condition characterized by bronchoconstriction, inflammation, and increased mucus production. It does not typically present with absent breath sounds, deviation of the trachea, or hyperresonant percussion sounds. Wheezing is a common finding in asthma.

Choice B rationale:

Pneumothorax - This is the correct choice. The scenario describes classic signs of a tension pneumothorax, which is a medical emergency. The tracheal deviation, absence of breath sounds, and hyperresonant percussion note on the affected side are indicative of air accumulation in the pleural space, leading to lung collapse and displacement of mediastinal structures.

Choice C rationale:

Atelectasis - Atelectasis refers to the collapse or incomplete expansion of a lung or part of a lung. It can lead to decreased breath sounds on auscultation but does not usually cause tracheal deviation or hyperresonance on percussion. It is not the best fit for the described signs.

Choice D rationale:

Pneumonia - Pneumonia is an infection of the lung tissue that can cause symptoms like fever, cough, and productive sputum. Breath sounds may be diminished over the affected area due to consolidation, but the absence of breath sounds, tracheal deviation, and hyperresonance point more strongly toward a pneumothorax in this case.

A. Admission assessment of a new client. B. Evaluating changes to a client's pressure ulcer. C. Performing tracheostomy care on a client. D. Administering a blood transfusion to a client.

Correct Answer is C

Explanation

Choice A rationale:

Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.

Choice B rationale:

Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.

Choice C rationale:

This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.

Choice D rationale:

Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.

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A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Correct Answer is C

Explanation

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