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

Answer and Explanation

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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Correct Answer is D

Explanation

a. Encourage the client to ignore these thoughts and feelings: This invalidates the client's experience and might hinder the therapeutic relationship.
b. Promote safety and immediately terminate the relationship with the client: Termination is a last resort, and transference can be a valuable tool for therapy if addressed constructively.
c. Immediately reassign the client to another staff member: This avoids the issue and doesn't address the underlying cause of transference.
d. Help the client to clarify the meaning of the relationship, based on the present situation. (Correct) Transference is a phenomenon where a client unconsciously redirects emotions and feelings from significant figures in their past onto the nurse. A therapeutic response involves acknowledging these feelings and helping the client explore them in a safe and supportive environment

A. glucose intolerance resulting in hypoglycemia. B. endocrine imbalance causing amenorrhea. C. decreased metabolism causing cold intolerance. D. cardiac dysrhythmia resulting in cardiac arrest.

Correct Answer is D

Explanation

a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.

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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?

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Naxlex Comprehensive Predictor Exams

If a client demonstrates transference towards the nurse, how should the nurse respond?

Correct Answer is D

Explanation

Which major health complication is associated with a client diagnosed with anorexia nervosa, does the nurse assess as a priority?

Correct Answer is D

Explanation

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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?

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