Which client should the nurse delegate to the UAP for feeding?
1. A client who is lethargic and has a head injury
2. A client with a brainstem stroke and quadriplegia
3. A client who is confused and, at times, combative
4. A client after surgery to jaw and throat 3 days ago
3
3. The nurse delegates the client who is confused and occasionally combative after cautioning the UAP to approach the client in a calm, nonthreatening manner. In addi-tion, the nurse instructs the UAP to maintain personal safety, to notify coworkers when the UAP enters this client's room, and to keep the door open.
1, 2, and 4. The remaining clients require nursing assessment and judgment for feed-ing because each has a high risk of aspiration and the potential for an airway obstruc-tion or ineffective airway. The lethargic client may be too sleepy to cooperate with feeding and eating safely. The client with brainstem impairment is likely to have breathing difficulties because the respiratory center is in the brainstem and can have difficulties coordinating breathing and swallowing. The postoperative client is likely to have tracheal and esophageal edema to impede swallowing.
You might also like to view...
The nurse is caring for an Olympic athlete who reports she has not had a menstrual cycle for 6 months, ever since she started training for the next Olympic tryout. The nurse suspects the cause of this patient's amenorrhea is what?
A) Hypothalamus is not releasing gonadotropin-releasing hormone (GnRH) B) Absence of estrogen production C) Increased production of follicle-stimulating hormone (FSH) D) Decreased production of progesterone
The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula- or breast-feedings is to:
a. Prevent hyperglycemia. b. Provide fluids and protein. c. Decrease gastrointestinal motility. d. Prevent rapid emptying of the bilirubin from the bowel.
Nursing retention is an important focus for hospitals as we face a long-term nursing shortage in the future. Which of the following would most likely contribute to increased job satisfaction?
a. Increases in salary b. Hiring bonuses of up to $5000 to attract nurses to fill vacancies and improve staffing patterns c. Financial incentives and rewards for advanced certifications, such as the CCRN certification for critical care RNs d. An emphasis on establishing effective working relationships with the nurses
The client with is breathing 36 breaths per minute and has a SaO2 at 89%. Which is the best nursing diagnosis for this client?
1. Impaired tissue perfusion related to chronic obstructive pulmonary disease as evidenced by tachypnea and desaturation 2. Ineffective airway related to unknown etiology as evidenced by tachypnea and desaturation 3. Ineffective breathing pattern related to chronic obstructive pulmonary disease as evidenced by wheezing and breathlessness 4. Impaired gas exchange related to unknown cause as evidenced by tachypnea and desaturation