The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?
Listen to the breath sounds in all lung fields
Document the amount of output on the I & O sheet
Check the abdominal dressing for bleeding
Increase the IV fluid flow rate if the blood pressure is low
The Correct Answer is B
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
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Related Questions
Correct Answer is D
Explanation
a. While taking slow, deep breaths can help with relaxation and possibly with managing anxiety or panic attacks, it is not directly addressing the combined side effects of these medications.
b. Wearing sunscreen and avoiding midday sun exposure is important to prevent photosensitivity reactions caused by some antipsychotics, but it is not related to the combined effects of antipsychotics and beta-blockers.
c. Watching diet and engaging in physical activity are generally good health practices but do not specifically address the combined side effects of these medications.
d. "Rise slowly when you change position from lying to sitting or sitting to standing." Both antipsychotics and beta-adrenergic blocking agents can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or even fainting. Advising the client to rise slowly helps to prevent these effects and ensures the client’s safety
Correct Answer is B
Explanation
a. Sharing limited personal information: Sharing personal information can blur professional boundaries and make the client feel uncomfortable.
b. Being reliable, honest, and consistent during interactions: Predictability and consistency build trust, especially for someone with a condition that can distort reality.
c. Establishing personal contact with family members: Involving family members may not always be appropriate and could violate the client's privacy. It's best to proceed with the client's consent
d. Sitting close to the client to establish rapport: Sitting too close can be perceived as intrusive and might make the client feel uneasy.
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