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. Food is rapidly ingested without proper chewing: While this might happen in bulimia nervosa, it does not explain dental erosion.
b. Purging causes the depletion of dietary calcium: Calcium depletion could affect bones and teeth but is not the primary reason for the dental erosion seen in bulimia nervosa.
c. Poor dental and oral hygiene lead to dental caries: While poor hygiene can contribute to dental issues, the primary cause of dental deterioration in bulimia is the acid from vomiting.
d. Emesis from purging corrodes the tooth enamel. Frequent vomiting in bulimia nervosa exposes teeth to stomach acid, which erodes the enamel and leads to dental deterioration.
Correct Answer is A
Explanation
a. "You feel that your mother does not want you to come back home?" This response uses reflection, a therapeutic communication technique, to encourage the client to express and explore their feelings further.
b. "It's quite common for clients to feel that way after a lengthy hospitalization." While this normalizes the client's feelings, it might dismiss the client's unique emotional experience and does not invite further exploration.
c. "Why don't you talk to your mother? You may find out she doesn't feel that way." This response provides a solution but does not address the client's current emotional state or encourage them to express their feelings.
d. "Your mother seems like an understanding person. I'll help you approach her." This response makes an assumption about the mother and shifts the focus away from the client’s feelings.
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