A nurse is delegating care for a client.
Exhibit 1
Nurses' Notes 1000:
Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.
Assist the client with completing their food menu.
Document the client's urine output
Monitor the client for manifestations of aspiration pneumonia
initiate a referral with the speech language pathologist E. Instruct the client on swallowing techniques
Ambulate the client.
Obtain the client's vital signs.
Obtain the client's vital signs.
Correct Answer : B,F,G
Role of assistive personnel is activities of daily living, document input and output, obtain stable vitals as well assist clients in ambulating.
A. The choice of food should consider the risk of aspiration and should include soft food. The high-risk client needs the involvement of a nurse
C. Monitoring the client for features of aspiration pneumonia is in the scope of a registered nurse as it requires clinical judgment and knowledge. –
D. Initiating referral to a speech language pathologist is in the scope of a nurse.
E. Instructing on swallowing techniques is an intervention performed by nurses as it requires demonstration of safety techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acting as the client’s advocate requires the nurse to act in a way that protects the client’s interests, rights and promote dignity. Reminiscent therapy uses good memories to improve cognitive capacity and self-esteem. Requesting this referral, the nurse makes a crucial decision that is in the client’s best interest.
Correct Answer is A
Explanation
A. The client with active bleeding from a puncture wound in the groin is the highest priority because of the risk of severe blood loss, which can lead to hypovolemic shock. The nurse should quickly apply pressure to the wound, assess the extent of the bleeding, and prepare for emergency interventions.
B Active bleeding is part of crculation in the ABCs that comes after airway and breathing
C. Client could be having a kidney stone which is not a priority
D.These symptoms could indicate a pulmonary embolism or heart attack, but they may not be as immediately life-threatening as active bleeding.
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