Nokea
A nurse is delegating care for a client. Client has right-sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3 tasks the nurse should assign to assistive personnel.
- A. Assist the client with completing their food menu.
- B. Document the client's urine output
- C. Monitor the client for manifestations of aspiration pneumonia
- D. Initiate a referral with the speech language pathologist
- E. Instruct the client on swallowing techniques
- F. Ambulate the client.
- G. Obtain the client's vital signs.
Correct Answer: B,F,G
Rationale: Assistive personnel can document urine output, ambulate the client, and obtain vital signs, as these are low-risk tasks within their scope.
You may also like to solve these questions
A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Contact the case manager to discuss discharge options.
- B. Request another family member assist the client's partner with care.
- C. Ask the provider to delay the client's discharge home for a few more days.
- D. Recommend the partner place the client in a long-term care facility.
Correct Answer: A
Rationale: A case manager can explore alternative care options, such as home health or facility placement, to support the client and partner.
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take?
- A. Request that the coworker complete an incident report.
- B. File an anonymous report of the incident to the nurse manager.
- C. Identify all witnesses to the incident.
- D. Document a factual account of the incident.
- E. Submit an incident report to the risk manager.
Correct Answer: B,C,D,E
Rationale: Filing an anonymous report, identifying witnesses, documenting the incident, and submitting a report ensure accountability and prevent recurrence without workplace tension.
A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.