A nurse is delegating care to an assistive personnel. Which of the following assignments should the nurse make?

Taking the vital signs of a client who is experiencing acute angina

Collecting a urine specimen from a client who is experiencing dysuria

Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Reinforcing teaching with a client about stool specimen collection

Answer and Explanation

The Correct Answer is B

A.   Taking the vital signs of a client who is experiencing acute angina. Acute angina is a potentially unstable condition requiring assessment by a nurse.
B.   Collecting a urine specimen from a client who is experiencing dysuria. APs can perform routine specimen collection tasks.
C.   Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure. Only licensed nurses should provide pre-procedure instructions.
D.   Reinforcing teaching with a client about stool specimen collection. Reinforcement of teaching involves assessment and evaluation, which are the nurse’s responsibilities.

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Correct Answer is ["B","C","D"]

Explanation

A. Place throw rugs on uncarpeted floors in the client's home. Throw rugs are a tripping hazard and should be removed or secured.
B. Ensure the client wears non-skid slippers when walking around the house: Non-skid slippers provide traction and reduce the risk of slipping.
C. Encourage an annual review of the medications the client is taking. Many medications can cause dizziness or sedation, increasing fall risk, so regular medication reviews are essential.
D. Install a raised toilet seat in the client's bathroom. A raised toilet seat makes it easier for older adults to use the toilet and reduces the risk of falls when standing or sitting.
E. Attach full-length side rails to the client's bed. Full-length side rails can increase the risk of injury if the client attempts to climb over them. Half-rails may be safer.

A. Observe the client's verbal and nonverbal behaviors. B. Ask the client's adolescent child to act as an interpreter. C. Avoid the use of gestures. D. Speak directly to the interpreter.

Correct Answer is A

Explanation

A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

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A nurse is delegating care to an assistive personnel. Which of the following assignments should the nurse make?

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Naxlex Comprehensive Predictor Exams

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