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A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Store unused oxygen tanks horizontally.
- C. Check your oxygen equipment once each week.
- D. Do not adjust the oxygen flow rate.
Correct Answer: D
Rationale: The correct answer is D: Do not adjust the oxygen flow rate. This is crucial to prevent complications such as hypoxia or oxygen toxicity. Adjusting the flow rate without medical guidance can be dangerous. A: Using wool blankets can increase the risk of fire hazard. B: Storing unused oxygen tanks horizontally can cause leaks due to the pressure change. C: Checking equipment weekly is important, but not adjusting the flow rate is more critical for safety.
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A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
- A. Assigning the most competent RN to perform a central line dressing change
- B. Assigning the most efficient AP to perform glucometer monitoring for each client
- C. Assigning two assistive personnel (AP) to ambulate all clients
- D. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Correct Answer: D
Rationale: Correct Answer: D - Assigning a new graduate nurse to perform a wet-to-dry dressing change.
Rationale:
1. Wet-to-dry dressing changes require advanced skill and knowledge.
2. New graduate nurses may not have sufficient experience to perform this task safely.
3. Risk of complications such as infection or tissue damage is higher with inexperienced staff.
Summary of Other Choices:
A: Assigning the most competent RN to perform a central line dressing change - Competent RNs are appropriate for this task.
B: Assigning the most efficient AP to perform glucometer monitoring - Routine task suitable for AP.
C: Assigning two AP to ambulate all clients - Ensures safety and efficiency in patient care.
A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
- A. Fill the bath basin with tap water that is 39° C (102.2° F).
- B. Pull the curtain around the client's bed.
- C. Wash the client's arms and hands first.
- D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus.
Correct Answer: B
Rationale: The correct answer is B: Pull the curtain around the client's bed. This action ensures the client's privacy and maintains their dignity during the bathing process. By creating a physical barrier with the curtain, the nurse respects the client's autonomy and promotes a comfortable environment.
Choice A is incorrect because the water temperature specified may not be suitable for the client, as it is too hot. Choice C is incorrect as washing the arms and hands first may not be the most efficient or logical sequence for a full-body bath. Choice D is incorrect because wiping the client's eyes with a washcloth in that direction can introduce contaminants into the eyes.
An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
- A. Palpate for possible bladder distention.
- B. Observe the incision site.
- C. Change the abdominal dressing.
- D. Obtain vital signs.
Correct Answer: D
Rationale: The correct answer is D: Obtain vital signs. Vital signs are essential to assess the client's overall condition and determine the urgency of the situation. The AP can measure and report the vital signs to the nurse promptly. Palpating for bladder distention (choice A) requires a higher level of assessment and may indicate a complication postoperatively. Observing the incision site (choice B) involves assessing for signs of infection or other complications, which should be done by a nurse. Changing the abdominal dressing (choice C) requires sterile technique and assessment skills beyond the AP's scope. Therefore, delegating these tasks to the AP could delay necessary interventions.
A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
- A. Assisting a client to cough and deep breathe
- B. Application of antiembolic stockings
- C. Administration of an enema
- D. Assessing a client's sacrum for edema
Correct Answer: D
Rationale: The correct answer is D. The nurse should plan to perform the task of assessing a client's sacrum for edema. This task requires critical thinking and nursing judgment to assess for potential complications such as pressure ulcers. Nurses are trained to assess and identify abnormalities in a client's condition.
Choice A: Assisting a client to cough and deep breathe can be delegated to the AP as it is within their scope of practice.
Choice B: Application of antiembolic stockings is a task that can be safely delegated to the AP as it is a routine procedure that does not require nursing assessment.
Choice C: Administration of an enema is a task that can be delegated to the AP as it is a routine procedure that does not require nursing assessment.
A nurse manager is reviewing incident reports from the past month. Which of the following situations should the nurse prioritize for follow-up?
- A. A client received a meal tray with the wrong diet.
- B. An assistive personnel failed to report a client's low blood glucose level.
- C. A nurse documented a medication administration 30 minutes late.
- D. A client's call light was answered after a 10-minute delay.
Correct Answer: B
Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient. Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.