The nurse is delegating care for a client with a stroke who has dysphagia.
Which task is appropriate to assign to the unlicensed assistive personnel (UAP)?
Teach the client to use a chin-tuck technique when swallowing.
Position the client upright during meals and remain with the client.
Evaluate the client for signs of aspiration after meals.
Assess the client's swallowing ability before meals.
The Correct Answer is B
Delegation to unlicensed assistive personnel requires understanding the scope of practice regarding stable vs unstable clients. Knowledge of the nursing process, specifically the difference between assessment or teaching and implementation of standard safety tasks, is required for this decision.
Choice A rationale
Teaching is a core nursing responsibility that requires specialized knowledge and clinical judgment. UAPs cannot perform initial or formal education on therapeutic techniques like the chin tuck, as they are not trained to evaluate the effectiveness of teaching.
Choice B rationale
Positioning a client upright and providing supervision during meals are standard safety tasks within the UAP scope of practice. This intervention supports safe swallowing while allowing the UAP to assist the client in a stable, repetitive manner.
Choice C rationale
Evaluation is the final step of the nursing process and must be performed by a registered nurse. Identifying signs of aspiration requires clinical observation and interpretation of physiological data, which exceeds the training and role of the UAP.
Choice D rationale
Assessment of swallowing ability is a complex task that requires clinical expertise and judgment. The registered nurse must perform the initial and ongoing assessments to determine the client's risk level and the safety of the current feeding plan..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This scenario requires understanding of integumentary integrity and burn wound management. Knowledge of infection prevention and moist wound healing principles is essential. Partial-thickness burns involve the epidermis and dermis, necessitating protection of the newly exposed, vulnerable basement membrane to facilitate re-epithelialization.
Choice A rationale
. Antimicrobials prevent colonization of exposed dermis while nonadherent dressings maintain a moist environment. This facilitates cellular migration and prevents further trauma during future dressing changes. Protecting the bed from environmental pathogens is critical for healing and preventing secondary infection.
Choice B rationale
. Air exposure causes desiccation of the wound bed, which leads to cell death and delayed healing. Dry environments promote eschar formation, increasing the risk of scarring. Maintaining a moist interface is the gold standard for promoting rapid dermal repair.
Choice C rationale
. Dry gauze adheres to the wound exudate and causes significant tissue damage during removal. Tight application can also impair local capillary circulation, leading to ischemia. Dressings should be applied loosely enough to ensure adequate perfusion to the healing tissue.
Choice D rationale
. Intact blisters serve as a biological dressing, protecting the underlying dermis from infection. Removing them prematurely exposes the wound bed unnecessarily to the external environment. They should only be debrided if they are large enough to impede joint movement.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
The scenario requires applying knowledge of anticoagulation pharmacology and safety protocols for pulmonary embolism management. Nurses must monitor therapeutic levels, maintain reversal agents, and assess for complications like bleeding to ensure systemic stability and prevent further clot propagation during recovery.
Choice A rationale
Activated partial thromboplastin time measures the intrinsic pathway of coagulation. It is vital for monitoring unfractionated heparin therapy, with a normal range of 30 to 40 seconds. Prolonged values indicate a higher risk for spontaneous hemorrhage.
Choice B rationale
Protamine sulfate acts as a specific antagonist to neutralize the anticoagulant effects of heparin. Availability is critical for immediate reversal if life threatening bleeding occurs or if the activated partial thromboplastin time exceeds the safe therapeutic range.
Choice C rationale
The international normalized ratio assesses the extrinsic pathway, primarily for warfarin therapy. A normal range for healthy individuals is 0.8 to 1.2, but therapeutic targets for pulmonary embolism typically fall between 2.0 and 3.0.
Choice D rationale
Hematocrit and platelet levels indicate bone marrow function and blood volume. Significant drops in hematocrit suggest internal bleeding, while platelet monitoring is essential to detect heparin induced thrombocytopenia, a serious immune mediated complication of anticoagulant use.
Choice E rationale
Phytonadione, or Vitamin K, is the essential reversal agent for warfarin induced anticoagulation. It promotes the hepatic synthesis of clotting factors 2, 7, 9, and 10, effectively counteracting excessive anticoagulation and reducing the risk of hemorrhage.
Choice F rationale
Continuous physical assessment is necessary to identify early signs of coagulopathy. These include petechiae, ecchymosis, hematuria, or bleeding gums. Early detection allows for prompt dosage adjustments or the administration of reversal agents to prevent clinical deterioration.
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