A nurse is delegating tasks to an assistive personnel (AP). For which of the following clients should the nurse have the AP measure vital signs?
A client who has a new onset of weakness
A client who is requesting pain medication 2 days after surgery
A client who has a new onset of chest pain
A client who is transferring to the intensive care unit
The Correct Answer is B
Choice A reason: A new onset of weakness requires nursing assessment because it could indicate an acute change in condition such as stroke, electrolyte imbalance, or infection. Delegating vital signs in this case would be unsafe, as the nurse must perform a thorough assessment and determine appropriate interventions.
Choice B reason: A client requesting pain medication 2 days after surgery is stable enough for the AP to measure vital signs. This task is appropriate to delegate because the nurse can then use the vital signs to evaluate the client’s status before administering pain medication. The nurse retains responsibility for interpreting the results and deciding on medication administration, but the AP can safely collect the data.
Choice C reason: A new onset of chest pain is a potentially life-threatening emergency that requires immediate nursing assessment and intervention. Delegating vital signs in this situation would delay critical care. The nurse must personally assess the client, obtain vital signs, and initiate emergency protocols if necessary.
Choice D reason: A client transferring to the intensive care unit is unstable and requires close monitoring. The nurse must perform a comprehensive assessment and obtain vital signs themselves to ensure accurate evaluation before and during transfer. Delegating this task would be inappropriate because of the client’s critical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Older adults have an increased risk, not decreased risk, for atelectasis due to reduced lung elasticity, weaker respiratory muscles, and decreased cough reflex.
Choice B reason: Diaphragmatic movement decreases with age because of muscle weakening and changes in thoracic structure. Increased diaphragmatic movement is not an age-related change.
Choice C reason: Chest wall compliance decreases with age due to calcification of costal cartilage and stiffening of the thoracic cage. Increased compliance is incorrect.
Choice D reason: Decreased blood oxygenation is correct. Aging reduces alveolar surface area and capillary perfusion, leading to lower arterial oxygen levels. This physiologic change must be considered when planning activities to avoid hypoxemia and fatigue.
Correct Answer is A
Explanation
Choice A reason: Clients receiving radiation therapy should use gentle methods to clean the treatment area, such as a soft washcloth, to avoid irritating the skin. The skin in the treatment field is highly sensitive and prone to breakdown, so gentle care is essential.
Choice B reason: Dye markings are used to guide radiation therapy and must remain intact throughout the course of treatment. Removing them would interfere with accurate targeting of the radiation beam.
Choice C reason: While avoiding sun exposure is generally good advice, the specific instruction for radiation therapy is to protect the treatment area from trauma and irritation. Sun avoidance is important, but the more direct teaching point is gentle cleansing.
Choice D reason: Clothing should not rub or irritate the treatment area. Loose, soft clothing is recommended, but simply wearing clothing over the area is not the key teaching point. The priority is protecting the skin from irritation and maintaining the markings.
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