The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
What additional action should the nurse instruct the UAP to perform each time the client is turned?
Offer the client oral fluids.
Feed the client a snack.
Assess the breath sounds.
Empty the urinary drainage bag.
The Correct Answer is D
Choice A rationale
Offering the client oral fluids is important for hydration, but it may not be appropriate for all patients, especially those with certain medical conditions or those who are NPO (nothing by mouth)7.
Choice B rationale
Feeding the client a snack can help maintain energy levels, but it may not be appropriate for all patients, especially those with dietary restrictions or those who are NPO7.
Choice C rationale
Assessing breath sounds is an important part of respiratory assessment, but it is not typically within the scope of practice for unlicensed assistive personnel (UAP). This task should be performed by a licensed nurse.
Choice D rationale
Emptying the urinary drainage bag is an appropriate task for a UAP to perform each time the client is turned. This helps ensure accurate measurement of urinary output and prevents infection by keeping the bag below the level of the bladder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale
Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Correct Answer is A
Explanation
Choice A rationale
Oxygen therapy is a crucial part of the management for patients with severe pneumonia. However, prolonged administration of high concentrations of oxygen can potentially lead to oxygen toxicity, resulting in damage to the cells of the lungs. This is due to the production of
reactive oxygen species which can damage cell structures. Therefore, it is important to avoid administering oxygen at high levels for extended periods.
Choice B rationale
While it might seem logical to increase the oxygen rate during sleep due to a slower respiratory rate, this is not typically recommended. The body’s oxygen requirements do not significantly change during sleep and increasing the oxygen rate could potentially lead to hyperoxia.
Choice C rationale
Sedatives can indeed slow the respiratory rate, but this does not decrease oxygen needs. In fact, it could potentially lead to respiratory depression and hypoxia, especially in a patient with a respiratory illness like pneumonia.
Choice D rationale
Humidification of oxygen can improve patient comfort, especially with high flow rates, by preventing dryness in the nasal passages. However, it does not make oxygen less toxic.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.