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 D
Explanation
D) “I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.” This is an assertive response because it acknowledges the patient’s request, expresses the nurse’s feelings, and sets a clear boundary for acceptable behavior. Assertiveness is the ability to communicate one’s needs, opinions, and feelings in a respectful and confident manner.
“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.” is incorrect. This is a passive response because it does not address the patient’s rudeness or assert the nurse’s rights. Passive communication is the tendency to avoid conflict, suppress one’s feelings, and comply with others’ demands.
“Maybe I can get one of the aides to bring you something in a while.” is incorrect. This is an evasive response because it does not commit to fulfilling the patient’s request or confronting the patient’s attitude. Evasive communication is the tendency to avoid responsibility, give vague answers, and shift blame to others.
“Call the nursing station and ask them to have the kitchen bring whatever you want.” is incorrect. This is an aggressive response because it rejects the patient’s request, shows irritation, and implies that the nurse does not care about the patient’s needs. Aggressive communication is the tendency to dominate, criticize, and blame others.
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.
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