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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.
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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.
The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating
- A. false imprisonment.
- B. malpractice.
- C. negligence.
- D. invasion of privacy.
Correct Answer: A
Rationale: Barricading a client (A) constitutes false imprisonment, as it unlawfully restricts their freedom. Malpractice (B) involves substandard care, negligence (C) requires harm from a breach of duty, and invasion of privacy (D) involves unauthorized disclosure.
The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements best describes the purpose of referrals?
- A. Allows the nurse to demonstrate their leadership abilities.
- B. Care is appropriately routed to an individual or discipline.
- C. Ensures that care is unilateral and cost-effective.
- D. Focuses on empowering the client's decision making.
Correct Answer: B
Rationale: Referrals (B) ensure care is directed to the appropriate specialist or discipline to meet the client’s needs effectively. Demonstrating leadership (A) is secondary. Referrals do not ensure unilateral care (C) and are not primarily about client empowerment (D), though they may support it.
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A client with
- A. chronic anemia requiring epoetin injections.
- B. a resolving pneumothorax with a chest tube.
- C. a tracheostomy requiring intermittent suctioning.
- D. septic shock requiring multiple interventions intravenous (IV) and vasopressors.
Correct Answer: D
Rationale: Septic shock requiring IV vasopressors (D) is a critical condition needing RN expertise for titration and monitoring. Anemia (A), resolving pneumothorax (B), and tracheostomy suctioning (C, C)) are more stable or routine, suitable for LPN care under supervision.