A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.

Apply a condom catheter to a client who is incontinent.

Deliver a clean voided urine specimen to the laboratory.

Feed a client who has bilateral casts due to upper arm fractures.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.

B. Applying a condom catheter is important but can generally be done after more urgent tasks.

C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.

D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.

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Correct Answer is D

Explanation

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.

A. False imprisonment B. Assault C. Battery D. Negligence

Correct Answer is C

Explanation

Rationale:

A. False imprisonment involves restricting a person’s freedom of movement, not administering medication against their will.

B. Assault involves the threat of harm, not the actual administration of medication.

C. Battery is the intentional touching of another person without consent, which includes administering medication to a competent person who has refused it.

D. Negligence involves failure to meet the standard of care, but administering medication against a patient’s wishes is more accurately described as battery.

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A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

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Naxlex Comprehensive Predictor Exams

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