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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.

Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.

Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.

Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.

A. The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage. B. The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine. C. The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C). D. The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.

Correct Answer is A

Explanation

Choice A Reason: This client has a potential airway obstruction and needs close monitoring by the nurse. Laryngeal nerve damage can cause vocal cord paralysis, which can lead to respiratory distress and aspiration.

Choice B Reason: This client needs education on the medication and its side effects, but this can be done by the PN under the supervision of the nurse. Levothyroxine is a synthetic thyroid hormone that replaces deficient hormones in hypothyroidism.

Choice C Reason: This client needs ongoing management of diabetes, but this can be done by the PN under the supervision of the nurse. Glycosylated Hgb (Hgb A1C) is a measure of the average blood glucose level over the past three months.

Choice D Reason: This client has a life-threatening condition that requires immediate treatment with corticosteroids, but this can be done by the PN under the supervision of the nurse. Addison's crisis is a severe form of adrenal insufficiency that causes hypotension, shock, and electrolyte imbalance.

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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?

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Correct Answer is B

Explanation

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

Correct Answer is A

Explanation

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