A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Removal of the nasogastric tube of a client who has been receiving enteral feedings

Monitoring vital signs of a client who had an appendectomy 12 hr ago

Application of antibiotic ointment to the arm of a client who has dermatitis

Obtaining medical history information from a stable client who is being admitted

Answer and Explanation

The Correct Answer is B

Rationale:

A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.

B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.

C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.

D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.

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Correct Answer is D

Explanation

Rationale:

A. Reviewing preoperative laboratory test results is within the nurse’s responsibilities to ensure that all necessary tests have been completed.

B. Assessing the current health status of the client is an important preoperative task for the nurse.

C. Ensuring a signed surgical consent form is completed is within the nurse’s scope to verify that informed consent has been obtained.

D. Explaining the operative procedure, risks, and benefits is typically the responsibility of the surgeon or provider, not the nurse.

A. A young adult client admitted for acute glomerulonephritis following a viral infection B. A dependent adult admitted for the treatment of a spiral fracture C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

Correct Answer is B

Explanation

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

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A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Correct Answer is D

Explanation

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

Correct Answer is B

Explanation

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