Nokea
All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:
- A. monitoring intravenous infusion
- B. assisting a client to the bathroom
- C. offering fluid intake every 1-2 hours
- D. monitoring/recording the amount of fluid taken
Correct Answer: A
Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.
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A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
- A. Physical therapist
- B. Occupational therapist
- C. Clergy
- D. Social worker
Correct Answer: D
Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition. Therefore, the correct answer is the social worker.
The nurse is teaching a client about communicable diseases and explains that a portal of entry is:
- A. a vector.
- B. a source, like contaminated water.
- C. food.
- D. the respiratory system.
Correct Answer: D
Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.
The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?
- A. Administering the medication
- B. Drawing up the medication in a syringe
- C. Planning to have the nurse on the next shift administer the medication
- D. Contacting the healthcare provider
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.
Under what circumstances is the legal right to confidentiality of client information waived?
- A. When a court system subpoenas information.
- B. When a family member requests health care information of a client.
- C. When a living will takes effect.
- D. When the client is declared incompetent by the legal system.
Correct Answer: A
Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.
An 85-year-old client is eligible for Medicare-reimbursable home care services. Referral is contingent on meeting which of the following criteria?
- A. homebound status, requiring skilled therapy care
- B. immediate previous hospitalization for acute care
- C. age
- D. requirement of nursing and social work support
Correct Answer: A
Rationale: The correct criteria for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as physical therapy, occupational therapy, speech therapy, nursing, or social work. Choice A is correct because it aligns with these requirements. Choice B is incorrect as immediate previous hospitalization is not a prerequisite for home care services. Choice C is incorrect as age alone does not determine eligibility for Medicare-reimbursable home care services. Choice D is incorrect as the requirement of nursing and social work support alone is not sufficient for Medicare-reimbursable home care services.