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Which task could the nurse safely delegate to the UAP?
- A. Oral feeding of a two-year-old child after application of a hip spica cast
- B. Assessment of the placement and patency of an NG tube
- C. Participation in staff rounds to record notes regarding client goals
- D. Evaluation of a client's incisional pain following narcotic administration
Correct Answer: A
Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.
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After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?
- A. Remove the air from the solution bag
- B. Obtain a piston syringe and irrigation set
- C. Record the solution added as fluid intake
- D. Calculate the rate of flow of the solution
Correct Answer: B
Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.
A nurse is caring for a 60-year-old man who is scheduled to have coronary bypass surgery in the morning. He tells the nurse that he is afraid that he will die and he is scared of the surgery. What is the best reply for this nurse to give him?
- A. There is no reason to be scared. My father had this surgery, and now he's playing tennis with his friends almost every day.
- B. I would be scared too. It's a natural thing to feel. Don't worry. Everything will be alright.
- C. You're scared?
- D. The doctor has performed hundreds of successful bypass surgeries. I have a lot of faith in him.
Correct Answer: C
Rationale: The best reply for the nurse to give the patient is option C: 'You're scared?' This response reflects empathy and understanding, acknowledging the patient's feelings of fear. By directly addressing the patient's emotions, the nurse encourages further expression of concerns, which is crucial in providing emotional support. Choices A and D may come off as dismissive of the patient's feelings by downplaying his fear or shifting the focus to others' experiences. Choice B, although acknowledging the patient's fear, does not actively engage with the patient's emotions or encourage further discussion.
When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?
- A. Monitoring for signs of fluid overload.
- B. Ensuring the client receives enough fluids to prevent dehydration.
- C. Preventing electrolyte imbalances.
- D. Maintaining the prescribed rate of fluid administration.
Correct Answer: A
Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.
After administering pantoprazole to a client with gastroesophageal reflux disease (GERD), which statement by the client indicates to the nurse that the medication is producing the desired effect?
- A. After eating my meal, I did not experience any heartburn
- B. I have a great appetite and am feeling really hungry
- C. I should increase the amount of vitamin C in my diet
- D. While eating, I had no difficulty swallowing any of the foods
Correct Answer: A
Rationale: The correct answer is A. Pantoprazole reduces stomach acid production, thus preventing the occurrence of heartburn after meals, which is a common symptom of GERD. Choice B is incorrect because an increased appetite and hunger are not indicators of the desired effect of pantoprazole. Choice C is unrelated to the medication's effect on GERD symptoms. Choice D is also incorrect because the absence of difficulty swallowing is not a specific indicator of pantoprazole's effectiveness in treating GERD.
How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?
- A. The goals set by the client
- B. The learning level of the client
- C. Assessing the home environment
- D. The distractions in the client's home
Correct Answer: C
Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.