A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coffee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)
Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding
Stop administering the tube feeding and assist the client who spilled coffee with changing her wet clothing and
assess for burns
Request a replacement tray and assist the client with changing her wet clothing
Correct Answer : B
Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coffee. The nurse should not delay providing care for a client who may have suffered a burn.
Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coffee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.
Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coffee. The nurse should not focus on replacing the tray before assessing for burns.
Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coffee.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because placing soiled linens in the dirty linen receptacle can expose other clients and staff to the hepatitis virus, which can be transmited through blood and body fluids.
Choice B reason: This is incorrect because placing soiled linens on the floor can create a safety hazard and a potential source of infection for anyone who comes in contact with them.
Choice C reason: This is correct because placing soiled linens in a plastic bag that has the contamination symbol can prevent the spread of infection and alert the laundry department to handle them with caution.
Choice D reason: This is incorrect because placing soiled linens in the hazardous waste receptacle can waste resources and violate the regulations for disposing of hazardous materials.
Correct Answer is C
Explanation
Choice A reason: Collects data is not an activity that the nurse performs during the planning step of the nursing process. Collecting data is an activity that the nurse performs during the assessment step of the nursing process, which involves gathering and analyzing information about the client’s health status, history, and environment.
Therefore, this choice is incorrect.
Choice B reason: Records data is not an activity that the nurse performs during the planning step of the nursing process. Recording data is an activity that the nurse performs during the documentation step of the nursing process, which involves writing or entering the data and findings in the client’s record or chart. Therefore, this choice is incorrect.
Choice C reason: Prioritizes care is an activity that the nurse performs during the planning step of the nursing process. Prioritizing care is an activity that involves ranking the client’s problems, needs, or risks according to their urgency, importance, or potential impact. It helps the nurse to allocate time and resources efficiently, and to address the most critical or significant issues first. Therefore, this choice is correct.
Choice D reason: Carries out interventions is not an activity that the nurse performs during the planning step of the nursing process. Carrying out interventions is an activity that the nurse performs during the implementation step of the nursing process, which involves executing the plan of care and performing the interventions and activities that were planned. Therefore, this choice is incorrect.
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