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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

Answer and Explanation

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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Correct Answer is ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

A. Place them in the dirty linen receptacle B. Place them on the ﬂoor until the laundry department can pick them up C. Place them in a plastic bag that has the contamination symbol D. Place them in the hazardous waste receptacle

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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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

Correct Answer is ["B"]

Explanation

What should the nurse do with linens that have been soiled by a client with hepatitis?

Correct Answer is C

Explanation

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