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A nurse is caring for a client who is postoperative following a total knee replacement. The client reports numbness in the operative leg. Which of the following actions should the nurse take first?
- A. Administer a prescribed analgesic.
- B. Notify the provider of the numbness.
- C. Elevate the client's leg on pillows.
- D. Document the client's report in the medical record.
Correct Answer: B
Rationale: Notifying the provider of numbness is critical, as it may indicate a complication such as nerve damage or compartment syndrome, requiring immediate evaluation.
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A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
- A. The nurse relinquishes accountability for client outcomes when care is delegated to an AP.
- B. The nurse should consider the AP's level of experience when making delegation decisions.
- C. The AP can provide client education about how to perform basic self-care to the client.
- D. The AP can re-delegate a task to another AP who has similar work experience.
Correct Answer: B
Rationale: The correct answer is B: The nurse should consider the AP's level of experience when making delegation decisions. This answer demonstrates an understanding of the key principle of delegation, which is to assign tasks based on the competency and skill level of the individual. Considering the AP's experience ensures safe and effective delegation.
Incorrect choices:
A: Incorrect because the nurse remains accountable for client outcomes even when delegating tasks.
C: Incorrect because client education should typically be done by licensed healthcare providers.
D: Incorrect because delegation should not involve re-delegating tasks to another uninvolved AP.
In summary, choice B reflects the importance of assessing the AP's competency when delegating tasks, ensuring safe and quality care.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
- A. Ambulate an older adult client who has hypertension.
- B. Provide discharge instructions for a client who has a new skin graft.
- C. Check a blood product with another nurse prior to administration.
- D. Weigh a client who has heart failure.
- E. Perform an admission assessment on a client.
Correct Answer: A,D
Rationale: The correct tasks to assign to an assistive personnel (AP) are A and D. APs are trained to assist with basic care activities. Ambulating an older adult client with hypertension and weighing a client with heart failure are within the scope of practice for APs as they do not involve complex assessments or critical decision-making. Providing discharge instructions (B) requires specialized knowledge and education, which is beyond the scope of an AP. Checking a blood product (C) and performing an admission assessment (E) require specific training and expertise that only licensed nurses should perform.
A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?
- A. Make a copy of the incident report for the provider.
- B. Submit the incident report to the risk manager.
- C. Place the incident report in the client's chart.
- D. Document in the chart that an incidence report has been filed.
Correct Answer: B
Rationale: The correct answer is B: Submit the incident report to the risk manager. This is the appropriate action because the risk manager is responsible for analyzing incidents to identify potential risks and implementing strategies to prevent them in the future. Providing the report to the risk manager allows for a comprehensive review and implementation of necessary measures.
Choice A is incorrect because making a copy of the incident report for the provider does not ensure that the incident is properly analyzed and addressed. Choice C is incorrect as placing the incident report in the client's chart may not reach the appropriate personnel for further action. Choice D is incorrect because simply documenting in the chart that a report has been filed does not facilitate a comprehensive review by the risk management team.
A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?
- A. Nurses and other emergency medical personnel
- B. Responding law enforcement officers
- C. Members of the Federal Emergency Management Agency (FEMA)
- D. Representatives from the American Red Cross
Correct Answer: A
Rationale: The correct answer is A because nurses and other emergency medical personnel are trained to assess and prioritize patients based on their medical needs during a disaster. They have the expertise to quickly identify and categorize patients to ensure those with the most critical conditions receive immediate care. Responding law enforcement officers (B) focus on security and crowd control. Members of FEMA (C) are responsible for coordinating disaster response at a larger scale. Representatives from the American Red Cross (D) provide support services but do not typically serve as triage officers.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.