Nokea
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
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A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
- A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
- B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
- C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
- D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Correct Answer: D
Rationale: The correct answer is D because a significant drop in blood pressure from 138/86 mm Hg at 0800 to 106/60 mm Hg at 1200 indicates potential hypotension, which could be a sign of hemorrhage or shock postoperatively. Hypotension can lead to inadequate tissue perfusion and organ damage. Monitoring and addressing the client's blood pressure promptly is crucial to prevent further complications.
Choice A is not the priority because an increase in pain from 4 to 6 is significant but does not indicate as immediate risk as hypotension. Choice B, a change in wound drainage consistency, may require monitoring but is not as urgent as addressing hypotension. Choice C, an increase in post-meal blood glucose, is important but does not pose an immediate threat to the client's life compared to hypotension in Choice D.
A charge nurse is assigning tasks for a client who is postoperative following a cholecystectomy. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)?
- A. Assess the client's incisional pain.
- B. Assist the client with ambulation to the bathroom.
- C. Evaluate the client's response to pain medication.
- D. Monitor the client's surgical drain output.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The charge nurse should delegate assisting the client with ambulation to the bathroom to an assistive personnel (AP) as it is within the AP's scope of practice and does not require specialized nursing knowledge. This task helps promote the client's mobility and independence postoperatively. The AP can provide physical support and ensure the client's safety during ambulation.
Incorrect Choices:
A: Assessing the client's incisional pain requires nursing judgment and assessment skills, which should be done by a licensed nurse.
C: Evaluating the client's response to pain medication involves assessing for effectiveness, side effects, and potential complications, which requires nursing knowledge and assessment skills.
D: Monitoring the client's surgical drain output involves assessing for signs of infection, leakage, or other complications that require nursing judgment and intervention.
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
- A. Measuring a client's 1&O
- B. Obtaining a client's weight
- C. Providing postmortem care for a client
- D. Inserting a nasogastric tube for a client
Correct Answer: D
Rationale: Correct Answer: D - Inserting a nasogastric tube for a client
Rationale: LPNs are trained to perform more complex nursing tasks than APs. Inserting a nasogastric tube requires specialized skills and knowledge that LPNs are educated and licensed to carry out safely. LPNs have the training to assess, insert, and manage nasogastric tubes under the supervision of an RN, making this task appropriate for delegation to an LPN.
Incorrect Choices:
A: Measuring a client's 1&O - This task can be safely performed by an AP as it does not require the clinical judgment and skills of an LPN.
B: Obtaining a client's weight - This is within the scope of practice for an AP and does not require the nursing expertise of an LPN.
C: Providing postmortem care for a client - This task involves specialized knowledge and emotional support, typically handled by RNs, not LPNs.
A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?
- A. Determine the social skills of the AP.
- B. Assess the AP's ability to follow the client's teaching plan.
- C. Provide a clear description of the task to the AP.
- D. Evaluate the ability of the AP to work with peers.
Correct Answer: C
Rationale: The correct answer is C: Provide a clear description of the task to the AP. This is essential in delegation to ensure the AP understands what is expected. Determining social skills (A) and evaluating ability to work with peers (D) are not directly related to task delegation. Assessing ability to follow a teaching plan (B) is important but not the primary focus in task delegation.