Nokea
According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Select all that apply.
- A. Right task
- B. Right circumstance
- C. Right person
- D. Right direction and communication
Correct Answer: A, B, C, D
Rationale: The five rights of delegation per NCSBN include right task (A), circumstance (B), person (C), direction/communication (D), and supervision (not listed). All listed options are correct.
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The nurse is performing an assessment on an older adult. Which finding requires immediate followup?
- A. dysphagia
- B. stress incontinence
- C. dry, flaky skin
- D. hearing loss
Correct Answer: A
Rationale: Dysphagia (A) in older adults risks aspiration and malnutrition, requiring immediate follow-up to ensure safety. Stress incontinence (B), dry skin (C), and hearing loss (D) are common but less urgent concerns.
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.
The charge nurse plans client care assignments for an unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources?
- A. Perform wound care and dressing changes
- B. Collect routine vital signs (VS)
- C. Turn all bedbound clients every two hours
- D. Ambulate clients with ambulation orders
Correct Answer: A
Rationale: Wound care and dressing changes (A) utilize the LPN/VN’s clinical skills, maximizing resources. Vital signs (B), turning (C), and ambulation (D) are within UAP scope, allowing the LPN/VN to focus on higher-skill tasks.
The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. is repeatedly washing their hands.
- B. talking over others during group therapy.
- C. yelling and shouting at others.
- D. is voluntarily admitted and requesting discharge.
Correct Answer: C
Rationale: Yelling and shouting at others (C) indicates potential agitation or safety risk, requiring immediate follow-up to de-escalate and ensure unit safety. Hand washing (A), interrupting therapy (B), and discharge requests (D) are less urgent.