A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Acute respiratory acidosis occurs when there is inadequate excretion of carbon dioxide due to respiratory dysfunction, leading to an increase in carbon dioxide levels (hypercapnia) and subsequent acidosis (decrease in pH).

Manifestations of acute respiratory acidosis include:

A. Circumoral numbness and tingling - This is associated with respiratory alkalosis, not acidosis. B. Muscle flaccidity - This is more commonly seen in hyperkalemia or conditions affecting neuromuscular transmission. C. Decreased level of consciousness - This is a key manifestation of acute respiratory acidosis due to the effects of hypercapnia on the central nervous system. D. Cool, clammy skin - This is not typically associated with acute respiratory acidosis; instead, it might be seen in shock or hypoperfusion states.

Therefore, the nurse should expect to find a decreased level of consciousness in a client experiencing acute respiratory acidosis.

A. Provide educational material written at an eighth-grade reading level B. Ensure privacy for the client. C. Start with the least important information. D. Dim the lights in the client's room.

Correct Answer is A

Explanation

A. Provide educational material written at an eighth-grade reading level: This is correct. Health education materials should be written at a level that is easily understandable by the majority of patients. An eighth-grade reading level is often recommended to ensure that the information is accessible to a wide range of patients.

B. Ensure privacy for the client: This is also correct. Privacy is a fundamental right of all patients and is particularly important when discussing sensitive topics such as preoperative care. Ensuring privacy can help the patient feel more comfortable and facilitate open communication.

C. Start with the least important information: This is not recommended. When providing education, it’s generally best to start with the most important information. Patients may be anxious or overwhelmed, and they may not remember everything that is discussed. By starting with the most important information, you increase the chances that the patient will remember and understand the key points.

D. Dim the lights in the client’s room: While creating a comfortable environment is important, dimming the lights is not specifically related to preoperative teaching. The focus should be on providing clear, understandable information and addressing the patient’s questions and concerns.

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 nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Correct Answer is C

Explanation

A nurse is assisting with a preoperative teaching plan for a client. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

A nurse is assisting with a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?

A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medication should the nurse plan to administer first?

A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?