In helping a client such a Ms. C, who had a colostomy with a bowel resection, which tasks can be delegated to the UAP? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Assist Ms. C with perineal care. This task can be safely delegated to an Unlicensed Assistive Personnel (UAP) as it involves basic hygiene and does not require specialized medical training. Perineal care includes cleaning the area around the stoma, which is important for maintaining skin integrity and preventing infection. UAPs can be trained to provide this type of care under the supervision of a registered nurse. Choices B, C, and D involve more specialized skills such as proper positioning of the adhesive wafer, measuring colostomy contents, and reapplying a new colostomy bag, which should be performed by a licensed healthcare professional such as a nurse. Delegating these tasks to a UAP could pose a risk to the client's health and safety.

Correct Answer: A

Rationale: The correct answer is A: Severe dyspnea. In a tension pneumothorax, air accumulates in the pleural space, increasing pressure in the chest cavity, leading to severe dyspnea due to impaired lung expansion. Extreme agitation (B) is not a typical finding. Tracheal deviation (C) is seen in tension pneumothorax, not always present. Progressive cyanosis (D) may occur but is not as specific as severe dyspnea.

Correct Answer: C

Rationale: Correct Answer: C - The nurse has used medical jargon, which might not be understood by the patient. Rationale: 1. "TPR" and "PRN" are medical abbreviations that may not be familiar to the patient. 2. Using medical jargon can lead to confusion and miscommunication. 3. Effective communication in healthcare requires using language that the patient can easily understand. 4. It is important for the nurse to ensure clear and concise communication to promote patient understanding and cooperation. Summary of other choices: A: This choice is incorrect because using terminology that the patient may not understand does not constitute clear communication. B: This choice is incorrect because providing relevant information, even if technical, is not unnecessary if it aids in patient understanding. D: This choice is incorrect because simply stating what is happening without ensuring understanding does not address the issue of effective communication.

Correct Answer: C

Rationale: The correct answer is C because acting in a trustworthy and reliable manner and respecting the individuality of the patient are key components in building rapport. By being trustworthy, the nurse establishes a sense of security and reliability, which is crucial in a patient-nurse relationship. Respecting the patient's individuality shows empathy and understanding, making the patient feel valued and heard. Option A is incorrect because although introducing oneself is important, doing it repeatedly may come off as impersonal. Option B is incorrect as sharing personal experiences can blur professional boundaries and shift the focus away from the patient. Option D is incorrect as sharing information about other patients violates their privacy and confidentiality, which can damage trust and rapport with the patient.

Correct Answer: B

Rationale: Step 1: Disturbed auditory perception means there is a deficit in the ability to receive/process auditory information. Step 2: Speaking slowly and distinctly helps the patient better understand and process the information. Step 3: Shouting may distort the sound and further confuse the patient. Step 4: Other options (A, C, D) address different sensory deficits and are not directly related to disturbed auditory perception.