In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

Maintain low intermittent suction.

Secure the tube to the client's nose.

Ensure correct placement of the tube.

Replace the canister when full.

Answer and Explanation

The Correct Answer is B

A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.

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Correct Answer is D

Explanation

A. While postmenopausal use of herbal estrogen may be a risk factor for breast cancer, it is not as significant as having a family history of the disease.
B. A history of fibrocystic changes and a painful lump are not as strong a risk factor for breast cancer as a family history of the disease.
C. Being of normal weight, height, and having children at a younger age are generally considered protective factors rather than risk factors for breast cancer.
D. A non-tender lump combined with a family history of breast cancer (mother with breast cancer) is the most significant risk factor for developing breast cancer.

A. Respiratory rate 18 breaths/minute B. Heart rate 101 beats/minute C. Capillary refill 2 seconds D. Breath sounds clear and equal bilaterally E. Turban dressing is saturated with serosanguinous drainage F. Blood pressure 140/84 mm Hg G. Temperature 101.9° F (38.8° C) H. Client is awake and alert

Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

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In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 56-year-old female client has discovered a new breast lump. The practical nurse (PN) recognizes that this client's greatest risk for a diagnosis of breast cancer is related to which factor?

Correct Answer is D

Explanation

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior should the PN document as evidence of cocaine withdrawal?

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