The nurse determines that an elderly client with pneumonia has a nursing problem of "altered nutrition, less than body requirements." Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?
Offer to assist the client with meal preparation and feeding.
Thicken the client's liquids if aspiration seems likely.
Listen to the client's breath sounds before and after meals.
Assist the client in selecting high protein foods on the menu.
The Correct Answer is A
Choice A Reason: This is the best action because it helps the client meet their nutritional needs and prevents further weight loss. The nurse should delegate tasks that are within the scope of practice of the UAP, such as feeding assistance.
Choice B Reason: This is not an appropriate action because it requires a nursing assessment and intervention. The nurse should determine if the client is at risk for aspiration and consult with a speech therapist or dietitian before modifying the client's diet.
Choice C Reason: This is not a relevant action because it does not address the nursing problem of altered nutrition. The nurse should monitor the client's respiratory status and oxygenation, but this is not a task that can be delegated to the UAP.
Choice D Reason: This is not a sufficient action because it does not ensure that the client will consume enough food. The nurse should educate the client on the importance of high-protein foods, but this is not a task that can be delegated to the UAP.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Ensuring the transfer of the client's electronic chart code is not the most important action for the nurse to take first. The electronic chart code is a unique identifier that allows access to the client's health records and care plan. While this is an important task, it is not as urgent or essential as giving a detailed report to the accepting nurse, who will be responsible for providing palliative care to the client.
Choice B Reason: Giving a detailed report to the accepting nurse is the most important action for the nurse to take first. The report should include the client's diagnosis, prognosis, pain level, medication regimen, preferences, goals, and psychosocial needs. This will ensure continuity of care and facilitate a smooth transition for the client and the family.
Choice C Reason: Taking the family to the client's new room is not the most important action for the nurse to take first. The family may need emotional support and guidance during this difficult time, but they also need accurate and timely information about the client's condition and care plan. The nurse should first give a detailed report to the accepting nurse and then accompany the family to the new room.
Choice D Reason: Giving the client written information about end-of-life care is not the most important action for the nurse to take first. The client may benefit from learning more about palliative care, hospice care, advance directives, and bereavement services, but this should be done after giving a detailed report to the accepting nurse and ensuring that the client is comfortable and stable in the new room.
Correct Answer is D
Explanation
Choice A Reason: Remaining with this client and monitoring the vital signs while the nurse takes the call is not an appropriate instruction for the unit clerk. The unit clerk is not qualified to monitor vital signs or provide direct care to clients. The nurse should delegate this task to another licensed nurse or UAP who has been trained and validated in this skill.
Choice B Reason: Asking the healthcare provider to remain on "hold" until the nurse can confirm the prescription is not an appropriate instruction for the unit clerk. The unit clerk is not authorized to take verbal or telephone orders from healthcare providers. Only licensed nurses or pharmacists can do so, following specific policies and procedures.
Choice C Reason: Writing down what is prescribed and then repeating it back to the healthcare provider is not an appropriate instruction for the unit clerk. The unit clerk is not authorized to take verbal or telephone orders from healthcare providers. Only licensed nurses or pharmacists can do so, following specific policies and procedures.
Choice D Reason: Telling the healthcare provider the nurse will return the phone call as soon as possible is an appropriate instruction for the unit clerk. The unit clerk can relay messages between the healthcare provider and the nurse, but cannot take orders or give information about clients. The nurse should prioritize calling back the healthcare provider after stabilizing the unstable client.
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