Nokea
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following activities would be appropriate to delegate? Select all that apply.
- A. Performing initial client assessments
- B. Making client beds
- C. Giving clients bed baths
- D. Administering client medications
- E. Ambulating clients
- F. Assisting clients with meals
Correct Answer: B, C, E, F
Rationale: UAPs can make beds (B), give bed baths (C), ambulate clients (E), and assist with meals (F), as these are non-clinical tasks. Initial assessments (A) and medication administration (D) require nursing judgment, reserved for RNs or LPNs.
You may also like to solve these questions
The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis. The nurse should prioritize obtaining a prescription for
- A. intravenous fluids.
- B. ondansetron.
- C. the insertion of a nasogastric tube (NGT).
- D. fentanyl via patient-controlled analgesia.
Correct Answer: A
Rationale: IV fluids (A) are the priority in acute pancreatitis to correct hypovolemia and prevent organ failure, per clinical guidelines. Ondansetron (B), NGT (C), and fentanyl (D) address symptoms but are secondary to fluid resuscitation.
The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse?
- A. Assesses the client’s pulse by palpating the carotid artery.
- B. Allows for chest recoil after every chest compression.
- C. Compresses at a depth of 2 inches on the center breastbone.
- D. Asks for an automated external defibrillator after one cycle of CPR.
Correct Answer: C
Rationale: Compressing at a depth of 2 inches (C) is inadequate for adult CPR, as guidelines require 2.4 inches (6 cm) for effective circulation, requiring immediate correction. Pulse check (A), chest recoil (B), and requesting a defibrillator (D) are correct actions.
The charge nurse is planning client care assignments for a licensed practical/vocational nurse (LPN/VN). Which of the following would be an appropriate assignment(s) for the LPN? Select all that apply.
- A. A 67-year-old one-hour post-procedure from a cardiac catheterization.
- B. An 88-year-old client who was just admitted for intractable pain secondary to metastatic cancer.
- C. A 42-year-old being discharged following a diagnosis of type 2 diabetes mellitus.
- D. A 75-year-old inpatient client with colon cancer needing colostomy care.
- E. A 50-year-old client being treated for herpes zoster with prescribed oral antivirals.
Correct Answer: B, D, E
Rationale: LPNs can manage stable clients with pain (B), colostomy care (D), and oral antivirals (E) within their scope. A client one-hour post-cardiac catheterization (A) requires RN monitoring for complications, and discharge teaching for diabetes (C) involves complex education best suited for an RN.
The nurse is precepting a newly hired nurse on the medical-surgical unit. Which of the following actions, if performed first by the newly hired nurse, would demonstrate appropriate prioritization?
- A. Initiates a referral for a client needing home health care.
- B. Performs a central line dressing change on a client receiving 0.9% saline infusion.
- C. Collects a urine specimen from a client's indwelling urinary catheter.
- D. Obtains capillary blood glucose for a client receiving continuous regular insulin.
Correct Answer: D
Rationale: Obtaining blood glucose for a client on continuous insulin (D) is the priority to prevent hypo- or hyperglycemia, which can be life-threatening. Home health referral (A), dressing change (B), and urine collection (C) are important but less urgent, as they do not address immediate physiological risks.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.