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A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
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The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).
The nurse is gathering evidence for a quality improvement committee focused on fall prevention. To provide the highest quality scholarly evidence, the nurse plans on gathering findings from
- A. expert opinions.
- B. randomized controlled trials (RCTs).
- C. C. quantitative studies.
- D. D. qualitative studies.
Correct Answer: B
Rationale: Randomized controlled trials (B) provide the highest level of evidence for fall prevention due to their rigorous methodology. Expert opinions (A), quantitative studies (C), and qualitative studies (D) are lower in the evidence hierarchy.
“ Initiate intravenous fluids to a client with anorexia nervosa
Administer venlafaxine to a client with persistent depressive disorder
Consult the social worker to begin discharge planning for a client
Obtain a blood sample to evaluate a client's lithium level”
The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following?
- A. initiate intravenous fluids to a client with anorexia nervosa.
- B. administer venlafaxine to a client with persistent depressive disorder.
- C. consult the social worker to begin discharge planning for a client.
- D. obtain a blood sample to evaluate a client's lithium level.
Correct Answer: A
Rationale: Initiating IV fluids for anorexia nervosa (A) is the priority to address life-threatening dehydration and electrolyte imbalances. Administering venlafaxine (B), consulting a social worker (C), and obtaining a lithium level (D) are less urgent, as they do not address immediate physiological threats.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
The nurse has been made aware of the following client situations. The nurse should first assess the client who has
- A. bacterial meningitis and is receiving a third dose of intravenous doxycycline and reports a rash on their torso.
- B. a cerebral aneurysm and is nervous about their scheduled surgery in one hour.
- C. amyotrophic lateral sclerosis (ALS) and coughs when attempting to eat and drink.
- D. a migraine headache and has developed flushing after receiving prescribed intranasal sumatriptan.
Correct Answer: A
Rationale: A rash during doxycycline for meningitis (A) suggests a possible allergic reaction, a life-threatening complication requiring immediate assessment. Pre-surgical anxiety (B), ALS coughing (C), and sumatriptan flushing (D) are less acute, as they are expected or stable.