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","B","C"]
Explanation
Chronic pancreatitis involves long-term inflammation of the pancreas leading to permanent structural damage and functional impairment. Knowledge of pancreatic enzyme dynamics, calcium sequestration during fat necrosis, and the resulting endocrine dysfunction is essential to identify clinical manifestations and laboratory abnormalities.
Choice A rationale
Chronic inflammation causes cellular destruction and leakage of enzymes into the bloodstream. During acute exacerbations of chronic pancreatitis, serum amylase levels rise above the normal range of 23 to 85 U/L due to pancreatic ductal obstruction.
Choice B rationale
Fat necrosis leads to the release of free fatty acids, which bind with ionized calcium in a process called saponification. This results in hypocalcemia, where serum calcium levels fall below the normal 9.0 to 10.5 mg/dL.
Choice C rationale
Serum lipase is highly specific to the pancreas and increases during inflammatory episodes. Lipase levels remain elevated longer than amylase, exceeding the normal reference range of 0 to 160 U/L as pancreatic acinar cells undergo damage.
Choice D rationale
Chronic pancreatitis often leads to the destruction of insulin-producing beta cells in the islets of Langerhans. This typically results in secondary diabetes mellitus and hyperglycemia, rather than decreased serum glucose levels below the normal 70 to 99 mg/dL.
Choice E rationale
Hypocalcemia is the expected finding due to calcium binding in necrotic fat. Elevated serum calcium is not consistent with pancreatitis; in fact, hypercalcemia is sometimes a causative factor for pancreatitis rather than a clinical manifestation of the disease.
Correct Answer is D
Explanation
This case focuses on managing urolithiasis with signs of potential urinary obstruction. Knowledge of the nursing process, prioritization of physiological needs, and the distinction between pain management and critical organ perfusion/output is necessary to determine the first action.
Choice A rationale
Straining urine is important for stone analysis but is not the immediate priority for a client who hasn't voided in 6 hours. Assessment of the underlying cause of urinary retention must occur before focusing on stone recovery procedures.
Choice B rationale
Encouraging fluids helps flush stones but may exacerbate pain or vomiting if a total obstruction is present. The client's lack of output for 6 hours requires an assessment of bladder status before increasing fluid load significantly.
Choice C rationale
Pain management is essential for urolithiasis, but the lack of urinary output is a physiological priority. Assessing for bladder distention or obstruction ensures the kidneys are not sustaining damage from hydronephrosis before focusing solely on symptomatic relief.
Choice D rationale
Assessing for bladder distention is the priority to determine if the client is experiencing urinary retention due to obstruction. Identifying whether urine is being produced but trapped in the bladder is critical for preventing renal injury and hydronephrosis..
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