The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?
Determine which foods aggravate the client's symptoms.
Elevate the head of the bed before the client begins to eat.
Teach the client about the need to eat small, frequent meals.
Assess the client for heartburn or a feeling of fullness after eating.
The Correct Answer is B
Choice A rationale: Determining which foods aggravate the client's symptoms is beyond the scope of the UAP and should be addressed by licensed healthcare providers. Choice B rationale: Elevating the head of the bed before the client begins to eat helps prevent reflux in clients with hiatal hernia, and it's a task that can be delegated to the UAP.
Choice C rationale: Teaching the client about the need to eat small, frequent meals is a nursing responsibility and should be performed by a licensed nurse.
Choice D rationale: Assessing the client for heartburn or a feeling of fullness after eating is a nursing responsibility and requires a licensed nurse's judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D"]
Explanation
- Choice A Rationale: This choice is not optimal because the PN has the skills necessary to assist with the thoracentesis, a procedure that requires clinical judgment and skill, which the UAP does not possess. The RN is also needed to obtain the report from the ED due to the complexity of unstable angina, which requires advanced knowledge and assessment skills.
- Choice B Rationale: This option incorrectly assigns the UAP to prepare the room, which is within their scope, but fails to utilize the PN's skills effectively. The PN should be involved in more complex tasks such as assisting with procedures or obtaining detailed reports, rather than the UAP.
- Choice C Rationale: This choice is inappropriate because it assigns the UAP to assist with the thoracentesis, a task they are not trained for and is outside their scope of practice. The RN should be involved in the more complex care of obtaining the report, and the PN should assist with the thoracentesis.
- Choice D Rationale: This is the correct choice because it utilizes all staff members according to their scope of practice and skills. The PN assists with the thoracentesis, a task they are qualified for, the RN obtains the report on the new admission, which requires advanced knowledge, and the UAP prepares the room, a task that fits their role.
- Choice E Rationale: As there is no Choice E provided in the question, no rationale can be given for this option. It is important to follow the instructions and options given in the scenario to provide accurate and relevant information.
Correct Answer is D
Explanation
Choice A rationale: Instructing unlicensed assisted personnel to transfer non-ambulatory clients via wheelchairs may delay the evacuation process and put clients at risk. Choice B rationale: Announcing that visitors should proceed immediately to the first floor via the service elevators may cause congestion and hinder the evacuation of clients.
Choice C rationale: Shutting all doors to client rooms and telling everyone to stay in their rooms is not a safe strategy during a fire evacuation. It may increase the risk of harm to clients and staff.
Choice D rationale: Instructing the nursing staff to evacuate ambulatory clients to the nearest fire exits is the most appropriate and timely action to ensure the safety of both clients and staff during a fire evacuation.
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