An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?
Advise the client to maintain bedrest to ensure safety.
Instruct the UAP that all clients deserve equal care.
Determine the client's level of mobility and need for assistance.
Assign another UAP to care for the client.
The Correct Answer is C
Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.
Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.
Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.
Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Telling the parents that the procedure is 100% effective and safe is misleading and unethical. No medical procedure can be guaranteed to be completely effective and without risk.
Choice B reason: Providing the parents with ideas about how to make their child feel better after the procedure can be comforting and can help them feel more involved and prepared for post-procedure care.
Choice C reason: Finding a comfortable area for the parents to wait that is close to the procedure area can help reduce their anxiety by keeping them informed and involved in the process.
Choice D reason: Limiting visitation can increase anxiety as it separates the parents from their child, which can be distressing for both the child and the parents.
Choice E reason: Not providing any specifics on the amount of time the procedure will take can increase anxiety due to uncertainty. It is better to give a realistic time frame when possible.
Correct Answer is C
Explanation
The correct answer is: c. Inspiratory and expiratory bilateral crackles.
Choice A: Average urine output of 28 mL/hour
Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.
Choice B: Vesicular bibasilar breath sounds
Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.
Choice C: Inspiratory and expiratory bilateral crackles
Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.
Choice D: Central venous pressure of 12 mm Hg
Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.
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