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A nurse is preparing to discharge a client who has a new prescription for warfarin. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the client about dietary restrictions with warfarin.
- B. Provide the client with written discharge instructions.
- C. Assist the client with packing personal belongings.
- D. Schedule a follow-up appointment for the client.
Correct Answer: C
Rationale: Assisting the client with packing personal belongings is a non-clinical task within the AP's scope of practice. Teaching, providing instructions, and scheduling appointments require nursing expertise.
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A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Monitor the client's vital signs every 4 hours.
- B. Administer a prescribed benzodiazepine.
- C. Assess the client for tremors or agitation.
- D. Provide the client with a quiet environment.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a quiet environment. This task can be delegated to an assistive personnel (AP) because it involves creating a suitable environment for the client, which does not require specialized nursing skills. Assisting the client in a quiet environment can help minimize triggers and promote calmness during alcohol withdrawal.
A: Monitoring vital signs every 4 hours requires nursing judgment to interpret the results and decide on appropriate interventions.
B: Administering a benzodiazepine is a medication administration task that should be done by a nurse who can assess the client's condition and response to the medication.
C: Assessing the client for tremors or agitation involves clinical judgment and requires a nurse's expertise to determine the appropriate interventions.
In summary, providing a quiet environment is a task that can be safely delegated to an assistive personnel, while the other options involve assessments, medication administration, and clinical judgment that are within the scope of nursing practice.
A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
- A. A young adult client admitted for acute glomerulonephritis following a viral infection
- B. A dependent adult admitted for the treatment of a spiral fracture
- C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
- D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Correct Answer: B
Rationale: The correct answer is B because a dependent adult admitted for the treatment of a spiral fracture falls under mandatory reporting requirements for suspected abuse or neglect. The nurse is obligated to disclose information to an outside agency to ensure the safety and well-being of the patient. In cases of suspected abuse or neglect, it is crucial to involve external agencies to investigate and protect the vulnerable adult.
Choices A, C, and D do not necessarily involve mandatory reporting to an outside agency. A young adult with glomerulonephritis or asthma with possible IV drug abuse may not require immediate disclosure unless there is a clear indication of harm or risk to the patient. An emancipated minor with acute appendicitis wanting to leave without treatment raises ethical concerns but may not involve mandatory reporting unless there are specific legal requirements in place.
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
- A. The client who is in protective isolation
- B. The client who is actively dying and requires IV pain medication
- C. The client who is 3 days postoperative and requires a dressing change
- D. The client who requires frequent ambulation
Correct Answer: B
Rationale: The correct answer is B: The client who is actively dying and requires IV pain medication. The RN should assume responsibility for this client because as the registered nurse, they are the most qualified to manage complex care needs, such as IV pain medication administration and end-of-life care. The RN's advanced knowledge and skills make them best suited to provide appropriate assessment, intervention, and coordination of care in this critical situation.
Choice A is incorrect because the client in protective isolation requires meticulous adherence to infection control practices, which can be safely delegated to the LPNs or AP under the RN's supervision.
Choice C is incorrect as a dressing change for a client 3 days postoperative is within the scope of practice for the LPNs or AP and does not require the RN's direct involvement.
Choice D, the client requiring frequent ambulation, can be delegated to the LPNs or AP, as this task does not require the RN's specialized skill set.
A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?
- A. The National Council of State Boards of Nursing Decision Tree
- B. The state Nurse Practice Act
- C. The Omnibus Budget Reconciliation Act of 1987
- D. The National Association for Practical Nurse Education and Services
Correct Answer: B
Rationale: The correct answer is B: The state Nurse Practice Act. The Nurse Practice Act outlines the scope of practice and legal responsibilities for nurses in each state. When delegating tasks to an LPN, the nurse must adhere to the regulations and guidelines set forth in the Nurse Practice Act to ensure safe and appropriate delegation. Understanding this act is crucial to prevent legal and ethical violations.
Incorrect Choices:
A: The National Council of State Boards of Nursing Decision Tree - While this resource provides guidance on delegation, the Nurse Practice Act holds legal authority.
C: The Omnibus Budget Reconciliation Act of 1987 - This act relates to healthcare financing and does not specifically address the delegation of tasks to LPNs.
D: The National Association for Practical Nurse Education and Services - This organization focuses on education and services for LPNs but does not dictate legal guidelines for delegation.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.