A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?
Reinforcing teaching with a client about stool specimen collection
Collecting a urine specimen from a client who is experiencing dysuria
Taking the vital signs of a client who is experiencing acute angina
Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure
The Correct Answer is B
A) Reinforcing teaching with a client about stool specimen collection:
This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.
B) Collecting a urine specimen from a client who is experiencing dysuria:
Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.
C) Taking the vital signs of a client who is experiencing acute angina:
Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.
D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:
Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. Raisin toast
Rationale:
A. Soft-serve ice cream:
While soft-serve ice cream may seem appealing due to its mild taste and smooth texture, it can be high in sugar and fat, which might not be well-tolerated by patients experiencing chemotherapy-induced nausea. Heavy or rich foods can exacerbate nausea, making them less suitable for these clients.
B. Hot tea:
Hot tea can be soothing, but for individuals experiencing nausea, the warmth might not be well-received. Additionally, certain teas can contain caffeine, which may not be advisable for those undergoing chemotherapy, as it can sometimes exacerbate dehydration or jitters.
C. String cheese:
String cheese is a dairy product that can be heavy for some patients, particularly those experiencing nausea from chemotherapy. Dairy may cause gastric discomfort, and many patients may prefer lighter, less greasy options when feeling nauseous.
D. Raisin toast:
Raisin toast is a suitable choice as it is light, easy to digest, and contains carbohydrates that can help settle the stomach. The raisins add some natural sweetness without being overly rich, making it a good option for someone experiencing chemotherapy-induced nausea. This selection demonstrates an understanding of dietary choices that may be better tolerated during episodes of nausea.
Correct Answer is ["A","B","D","E"]
Explanation
A) Sublingual medication is crushed and administered through a client's gastrostomy tube: This scenario represents a violation of the client's right to refuse treatment or medication. Administering medication through a route other than the one prescribed without the client's consent is inappropriate and can result in harm or adverse effects.
B) Finger nail marks appear on a client's wrist after a radial pulse was taken: This scenario indicates a violation of the client's right to be free from abuse. Evidence of physical harm, such as finger nail marks, suggests that the client may have been handled roughly or experienced unnecessary force during the procedure, which is unacceptable.
C) Pain medication is administered 1 hr before a client has a dressing change: While administering pain medication slightly ahead of a painful procedure may be appropriate to provide optimal pain relief, it does not inherently violate the client's rights if it aligns with the client's pain management plan and preferences. Therefore, this scenario does not represent a clear violation of client rights.
D) The same indwelling urinary catheter is reinserted after a failed attempt: Reinserting the same urinary catheter after a failed attempt could represent a violation of the client's right to safe care and freedom from unnecessary discomfort. Repeated attempts at catheter insertion without clinical justification increase the risk of infection and discomfort for the client.
E) Medications scheduled four times a day are administered 2 hr after the scheduled time: Administering medications significantly late violates the client's right to receive care in a timely manner. Delayed medication administration can affect treatment efficacy and compromise the client's well-being, especially for medications with strict dosing schedules.
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