A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

The client needs routine wound care performed.

The client develops a postoperative fever.

The client is experiencing a therapeutic effect from their treatment.

The client needs strict measurement of intake and output

Answer and Explanation

The Correct Answer is B

A. The client needs routine wound care performed: Routine wound care is a stable, predictable task that can be delegated to assistive personnel. It does not require the judgment or assessment skills of a registered nurse.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or another complication that requires assessment, clinical judgment, and possible intervention by a registered nurse. This warrants transfer of care to the RN for evaluation and appropriate action.

C. The client is experiencing a therapeutic effect from their treatment: Observing a therapeutic response is expected and does not necessitate RN-only care. Monitoring for ongoing effectiveness can be performed by other trained personnel as appropriate.

D. The client needs strict measurement of intake and output: While accurate intake and output monitoring is important, it is a routine, measurable task that can be delegated to assistive personnel. It does not require RN assessment unless abnormalities are noted.

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Correct Answer is C

Explanation

A. Increased appetite: Radiation therapy often causes anorexia, nausea, and taste changes, leading to decreased appetite rather than an increase. Appetite suppression is a common side effect in clients receiving treatment for head and neck cancers.

B. Loose stools: Loose stools are not a typical side effect of external radiation to the throat. Gastrointestinal effects are more likely with abdominal or pelvic radiation.

C. Loss of taste: Radiation to the head and neck commonly affects the taste buds and salivary glands, resulting in dysgeusia or partial/complete loss of taste. This is an expected manifestation and can affect nutrition and quality of life.

D. Bladder infection: Radiation to the throat does not directly impact the urinary tract. Urinary tract infections are unrelated to external radiation for throat cancer unless there are other risk factors.

A. "When I sign the consent form. I am stating that the client appears to be competent to give consent." B. " I will sign the consent form to indicate that the client has received written materials explaining the procedure." C. “I will provide the client with an explanation of the procedure before I sign the consent form.” D. “It is my responsibility to obtain informed consent from the client prior to the procedure."

Correct Answer is A

Explanation

A. “When I sign the consent form, I am stating that the client appears to be competent to give consent.”: The nurse’s role in informed consent is to witness the client’s signature and verify that the client appears competent and is signing voluntarily. This demonstrates proper understanding of the nurse’s legal responsibility in the consent process.

B. “I will sign the consent form to indicate that the client has received written materials explaining the procedure.”: Providing written materials and explaining the procedure is the responsibility of the healthcare provider performing the procedure. The nurse does not sign the consent to verify that teaching has occurred.

C. “I will provide the client with an explanation of the procedure before I sign the consent form.”: Explaining the procedure, including risks and benefits, must be done by the provider who will perform it. The nurse may reinforce information but does not provide the primary explanation for consent.

D. “It is my responsibility to obtain informed consent from the client prior to the procedure.”: Obtaining informed consent is the legal responsibility of the provider performing the procedure. The nurse supports the process by witnessing the signature and ensuring consent is given voluntarily.

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A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

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