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During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP). Which of the following is the nurse's primary responsibility?
- A. Document the completion of the task.
- B. Make a list of tasks not yet completed to pass on to the next shift.
- C. Observe the UAP for the duration of the task.
- D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome.
Correct Answer: D
Rationale: The nurse’s primary responsibility is to follow up with the UAP (D) to ensure tasks are completed correctly and evaluate outcomes, maintaining accountability for delegated care. Documentation (A), listing incomplete tasks (B), and continuous observation (C) are not primary responsibilities.
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The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client
- A. immediately post-operative following a thyroidectomy.
- B. with a paralytic ileus requiring the management of a nasogastric tube.
- C. receiving intravenous magnesium sulfate for status asthmaticus.
- D. with a hypertensive crisis requiring initiation of intravenous nicardipine.
Correct Answer: B
Rationale: Managing a nasogastric tube for paralytic ileus (B) is within the LPN’s scope for stable clients. Post-thyroidectomy (A), magnesium sulfate (C), and hypertensive crisis (D) require RN monitoring due to critical risks.
During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.
The nurse is caring for a group of clients in the labor and delivery department. The nurse should prioritize assessing the client who
- A. is 39 weeks gestation with regular contractions every 3 minutes and reports perineal pressure.
- B. had an epidural placed 3 hours ago and reports a mild headache and has a distended bladder.
- C. delivered a term newborn 4 hours ago and has saturated one peri-pad since delivery and has a temperature of 99.6°F (37.6°C).
- D. is 37 weeks gestation with blood pressure 168/112 mmHg, reports a persistent headache.
Correct Answer: D
Rationale: Severe hypertension (168/112 mmHg) with headache at 37 weeks (D) suggests preeclampsia, a life-threatening emergency requiring immediate assessment to prevent seizures or organ damage. Perineal pressure (A), epidural headache (B), and postpartum findings (C) are less urgent.
The nurse has been tasked with developing and leading a multidisciplinary team to improve client safety and has been informed that previous group formations were unsuccessful due to poor team dynamics. When developing and leading this committee, it is essential that the nurse initially
- A. develop a code of conduct for the team.
- B. review how the team will be evaluated.
- C. review the goals for the team.
- D. establish deadlines for the team.
Correct Answer: C
Rationale: Reviewing team goals (C) initially aligns members toward a common purpose, addressing poor dynamics by fostering collaboration. A code of conduct (A), evaluation methods (B), and deadlines (D) are important but secondary to establishing shared objectives.