Nokea
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.
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A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?
- A. I had strep throat about one year ago.
- B. I got my flu shot at the pharmacy two weeks ago.
- C. I plan to continue nursing my baby until he is at least a year old.
- D. I am allergic to shellfish.
Correct Answer: C
Rationale: The correct answer is C. Glyburide is not recommended for use during breastfeeding as it can pass into breast milk and potentially harm the baby. Breastfeeding mothers should consult their healthcare provider for alternative medications. Choice A is unrelated, choice B and D are not contraindications for glyburide use.
A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?
- A. Measure 1&O for a client who has an indwelling urinary catheter.
- B. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.
- C. Develop a plan of care for a client who has cholecystitis.
- D. Complete an admission assessment for a client who has COPD.
Correct Answer: B
Rationale: The correct answer is B because reinforcing teaching to a client about medication administration falls within the scope of practice for an LPN. LPNs are trained to provide education on medication administration and can reinforce teaching provided by the nurse.
Choice A is incorrect because measuring intake and output for a client with an indwelling urinary catheter requires specific nursing assessment skills that LPNs may not have.
Choice C is incorrect because developing a plan of care for a client with cholecystitis involves critical thinking and decision-making skills typically performed by a registered nurse.
Choice D is incorrect as completing an admission assessment for a client with COPD requires comprehensive assessment skills that are typically within the scope of practice for a registered nurse.
Therefore, choice B is the most appropriate task to assign to an LPN in this scenario.
A nurse is caring for a client who is postoperative and has a new prescription for incentive spirometry. Which of the following tasks should the nurse perform?
- A. Teach the client how to use the incentive spirometer.
- B. Assist the client with ambulation to the hallway.
- C. Measure the client's oxygen saturation every 4 hours.
- D. Document the client's daily intake and output.
Correct Answer: A
Rationale: Teaching the client how to use the incentive spirometer requires nursing expertise to ensure proper technique and understanding, which is essential for preventing postoperative complications like pneumonia.
A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
- A. Inform the staff member of her appraisal time for that day prior to change-of-shift report.
- B. Schedule the appraisal interview as early in the shift as possible.
- C. Provide the staff member with a copy of the appraisal form in advance.
- D. Provide a chair directly across the desk for the staff member to sit in.
Correct Answer: C
Rationale: The correct answer is C: Provide the staff member with a copy of the appraisal form in advance. This action is essential as it allows the staff member to review the form, prepare their thoughts, and gather any necessary documentation or evidence to support their performance. By providing the form in advance, the staff member can actively participate in the appraisal process and engage in a meaningful discussion during the appraisal interview. This approach promotes transparency, fairness, and constructive feedback.
Other choices are incorrect:
A: Informing the staff member of the appraisal time prior to change-of-shift report may not give them adequate time to prepare for the appraisal.
B: Scheduling the appraisal interview as early in the shift as possible may not allow the staff member enough time to mentally prepare for the appraisal.
D: Providing a chair directly across the desk for the staff member to sit in is a physical setup and does not address the preparation aspect of the performance appraisal.
A nurse is caring for a client who is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead ECG.
- C. Notify the provider of the chest pain.
- D. Assess the client's pain characteristics.
Correct Answer: D
Rationale: Assessing the client's pain characteristics provides critical data to guide further actions, such as medication administration or diagnostic testing, and is the first step in managing chest pain.