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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.
Correct Answer is C
Explanation
a. Is pathological and warrants postponing the test: Not necessarily true. Mild anxiety is a normal human response to stressful situations. Postponing the test might reinforce avoidance behaviors.
b. May be transferred to classmates and result in test anxiety: While anxiety can be contagious in some situations, the nurse should focus on calming techniques for the individual experiencing it, not assuming it will spread.
c. is conducive to concentration and problem solving (Correct): Mild anxiety, also known as arousal, can heighten focus and alertness. This can be beneficial for tasks that require concentration, like tests. In some cases, it can improve cognitive function
d. Will interfere with cognitive ability: Extreme anxiety can be debilitating, but mild anxiety can actually enhance focus and performance in some situations.
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