A nurse is visiting with the family of a client who has just died. Which of the following actions should the nurse take to promote comfort for the family?
Allow the family as much time as they want with the client.
Use paper tape to hold the client's eyelids open.
Place the client in a supine position.
Avoid repeating information about the client's death.
The Correct Answer is A
The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.
a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.
b) Placing the client in a supine position is not necessary and may not be comfortable for the client.
c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.
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Correct Answer is B
Explanation
The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.
The other options are not typically within the scope of practice for an LPN:
a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.
c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.
d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.
Correct Answer is C
Explanation
When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.
The other options are not correct because:
a) The client should not bear down during rectal tube insertion.
b) Administering a second enema if results are not clear is not mentioned as a safety precaution.
d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.
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