A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Performing a simple dressing change on a client's foot

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile

Providing postmortem care for a client who has recently died

Emptying an indwelling urinary catheter bag for a client while wearing clean gloves

Answer and Explanation

The Correct Answer is B

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Provide the client with a list of eligible individuals who can serve as a health care proxy. - While it is important for clients to have information about selecting a healthcare proxy, the Patient Self-Determination Act does not specifically require nurses to provide a list of eligible individuals. However, nurses should educate clients about their rights to designate a healthcare proxy if desired.
B. Document in the client's medical record if the client has advance directives. - This is the correct action required by the Patient Self-Determination Act. The act mandates that healthcare facilities receiving Medicare or Medicaid funds must inform clients about their rights to make decisions about their medical care, including the right to have advance directives. Nurses are responsible for documenting in the client's medical record whether the client has advance directives, such as a living will or durable power of attorney for healthcare.
C. Provide end-of-life education if the client has a terminal illness. - While providing end-of-life education is important for clients with terminal illnesses, it is not specifically mandated by the Patient Self-Determination Act. However, the act does require healthcare facilities to inform clients about their rights to make decisions about end-of-life care, including the right to have advance directives.
D. Ensure the client has an attorney to contact for assistance with end-of-life documents. - The Patient Self-Determination Act does not mandate that nurses ensure clients have an attorney for assistance with end-of-life documents. While legal assistance may be helpful for some clients in completing advance directives, it is not a requirement of the act.

A. Add water to the formula. B. Reposition the NG tube. C. Increase the rate of formula delivery. D. Switch to a lactose-free formula.

Correct Answer is A

Explanation

A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Correct Answer is A

Explanation

A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?

A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

A nurse is teaching a client who has a new prescription for sertralihe to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?