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A charge nurse is assigning tasks for a client who is postoperative following a cholecystectomy. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)?
- A. Assess the client's incisional pain.
- B. Assist the client with ambulation to the bathroom.
- C. Evaluate the client's response to pain medication.
- D. Monitor the client's surgical drain output.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The charge nurse should delegate assisting the client with ambulation to the bathroom to an assistive personnel (AP) as it is within the AP's scope of practice and does not require specialized nursing knowledge. This task helps promote the client's mobility and independence postoperatively. The AP can provide physical support and ensure the client's safety during ambulation.
Incorrect Choices:
A: Assessing the client's incisional pain requires nursing judgment and assessment skills, which should be done by a licensed nurse.
C: Evaluating the client's response to pain medication involves assessing for effectiveness, side effects, and potential complications, which requires nursing knowledge and assessment skills.
D: Monitoring the client's surgical drain output involves assessing for signs of infection, leakage, or other complications that require nursing judgment and intervention.
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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barre syndrome
- B. A client who has a lumbosacral spinal tumor
- C. A client who has systemic sclerosis
- D. A client who has amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The correct answer is B. A client with a lumbosacral spinal tumor may need assistance with meals due to potential mobility limitations or weakness. The nurse can delegate this task to the AP as it falls within their scope of practice. Clients with Guillain-Barre syndrome (choice A) may have muscle weakness and difficulty swallowing, requiring skilled nursing assessment during mealtime. Clients with systemic sclerosis (choice C) may have gastrointestinal involvement, necessitating careful monitoring during meals. Clients with ALS (choice D) have progressive muscle weakness, making it crucial for a nurse to assess their ability to eat safely. Delegating meal assistance for these clients to an AP may compromise their safety.
A nurse manager is addressing a staff nurse's repeated tardiness. Which of the following approaches should the nurse manager use to promote professional accountability?
- A. Assign the nurse extra shifts to make up for lost time.
- B. Discuss the impact of tardiness on client care and team morale.
- C. Document the tardiness as a formal disciplinary action.
- D. Ignore the issue to avoid conflict with the nurse.
Correct Answer: B
Rationale: Discussing the impact of tardiness encourages the nurse to understand the consequences of their actions and take responsibility, promoting professional accountability.
Admission Assessment
Vital Signs
Nurses' Notes
82-year-old client admitted with nondisplaced hip fracture awaiting surgery. History of mild dementia, and hypotension. The family is concerned about malnutrition and living alone. The client's daughter who is the power of attorney (POA) is currently out of state.
A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room. The nurse is at risk for which of the following as evidenced by applying wrist restraints to the client?
- A. False imprisonment
- B. Slander
- C. Negligence
- D. Battery
- E. Assault
Correct Answer: A
Rationale: [1, 0, 0, 0, 0]
Correct Answer: A
Rationale: Applying wrist restraints without appropriate justification can lead to false imprisonment, violating the client's rights. Slander (B) is verbal defamation; Negligence (C) is failure to provide reasonable care; Battery (D) is physical harm; Assault (E) is the threat of harm.
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
- A. A client requesting a referral for home health services
- B. A client asking about his PCA pump that contains morphine
- C. A client who needs assistance with a bath
- D. A client who has questions about his new prescription
Correct Answer: B
Rationale: The correct answer is B. The nurse should plan to care for the client asking about his PCA pump with morphine first. This is because the client's inquiry relates to pain management, which is a priority in nursing care. Pain management directly impacts the client's comfort and well-being. Addressing the client's concerns about the PCA pump promptly ensures proper pain relief and prevents potential complications. Clients requesting referrals, assistance with baths, or questions about prescriptions can be attended to after the client with immediate pain management needs is addressed.
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.