A 73-year-old male patient has been admitted to an inpatient unit from the emergency room. He has been coughing severely for the past two days, has a headache, and a sore throat.

His COVID test is positive and he has Type II Diabetes. He denies any history of smoking.

His vital signs are as follows: Temperature - 101.0, Pulse - 84, Respiration - 24, Blood Pressure - 152/84, Pulse oximetry - 92%. The registered nurse (RN) delegates the collection of a urine specimen and Fasting Blood Sugar (FSBS) from the client to the nurse aide II. What are the responsibilities of the RN in regard to this delegated task?

Select all that apply.

Ensure the nurse aide has the required training to perform these tasks.

Maintain accountability for ensuring the delegated tasks are conducted correctly and completely.

Ensure policies cover the delegation.

Perform an assessment of the patient prior to delegation.

Observe all tasks performed by the nurse aide II.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
Administering a nebulizer treatment would be more appropriate for respiratory conditions such as asthma or COPD, not for angina pectoris.
Choice B rationale
Obtaining an EKG reading is the most appropriate initial action when a patient reports a new onset of angina pectoris. An EKG can help determine if the patient is experiencing a myocardial infarction (heart attack), which is a life-threatening condition.
Choice C rationale
While reviewing the patient’s surgical history is important in a comprehensive assessment, it is not the most immediate action needed when a patient presents with angina.
Choice D rationale
Recording the patient’s weight is not the most immediate action needed when a patient presents with angina.

A. Clients should designate a single area in the home for smoking while using oxygen. B. To prevent falls, throw rugs should have bright patterns. C. Carbon monoxide detectors should be strategically installed throughout the home. D. If any poison is ingested, ipecac should be administered to induce vomiting.

Correct Answer is C

Explanation

Choice A rationale
Designating a single area in the home for smoking while using oxygen is not a safe practice. Oxygen supports combustion and can cause materials to ignite more easily and burn faster, increasing the risk of fires and severe burns.
Choice B rationale
While bright patterns on throw rugs may make them more visible, they can still pose a tripping hazard, especially for older adults or individuals with mobility issues.
Choice C rationale
Installing carbon monoxide detectors throughout the home is a key safety measure. Carbon monoxide is a colorless, odorless gas that can cause sudden illness and death if inhaled.
Choice D rationale
Administering ipecac to induce vomiting after ingesting poison is not recommended. It can cause harm and is not effective for all types of poisonings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse’s initial action?

Correct Answer is B

Explanation

When teaching clients about maintaining a safe environment, which statement would be most suitable to include?

Correct Answer is C

Explanation

A nurse is teaching a patient how to change their surgical dressing. The patient is able to perform a return demonstration. Which learning domain has been demonstrated?

When caring for the patient with left sided heart failure, which of the following are subjective symptoms?

The nurse is caring for a client diagnosed with a systemic staphylococci infection from the client’s own flora. The nurse correctly notes that this is an example of a(n):

A patient has been discharged home following a hospital stay for a hip fracture sustained in a fall. The provider has ordered physical therapy to help the patient regain strength and flexibility. To which tertiary service is the patient likely to be referred?

The nurse observes that a patient is experiencing absolute homelessness. The nurse contacts a social worker to assist the patient with resources. Which term best describes the nurse’s actions?

A nurse is caring for a patient from Mexico and ensures to incorporate the patient’s cultural traditions, values, and beliefs into the care plan. Which nursing theorist’s principles does this action align with?

A diabetic client reports being terminated from their employment for using their glucose meter. Which law does this action infringe upon?

Which of the following is an example of indirect care?