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 strict measurement of intake and output.

The client develops a postoperative fever.

The client is experiencing a therapeutic effect from their treatment

The client needs routine wound care performed.

Answer and Explanation

The Correct Answer is B

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

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Correct Answer is C

Explanation

Rationale:

A. Put a simple lock on the client's bedroom door: Locking the client's door could pose a safety risk, especially in the event of an emergency such as a fire. It also restricts the client's autonomy and may increase confusion or agitation in clients with Alzheimer's disease.

B. Give the client a barbiturate medication at bedtime: Barbiturates are not recommended for older adults due to their sedating effects and risk of dependence, falls, and worsening cognitive function. Non-pharmacologic strategies are preferred first in managing sleep disturbances.

C. Encourage the client to take frequent walks during the day: Physical activity during the day helps reduce nighttime restlessness and improve sleep patterns. Walking can also help regulate circadian rhythms, promote relaxation, and reduce wandering behavior at night.

D. Allow the client to nap for at least 1 hr during the day: Long daytime naps may disrupt the sleep-wake cycle, worsening insomnia and nighttime wandering. Limiting daytime napping and encouraging activity is more effective in promoting restful nighttime sleep.

A. "Your child should have surgery in 7 to 10 days to remove the tumor." B. "You should not palpate your child's abdomen prior to surgery." C. "You should give your child captopril 200 mg PO daily." D. "Your child will not require further treatment after removal of the tumor.”

Correct Answer is B

Explanation

Rationale:

A. "Your child should have surgery in 7 to 10 days to remove the tumor.": Surgical removal of the tumor is a priority and is usually scheduled promptly after diagnosis, not delayed by a week or more. Early intervention reduces the risk of tumor rupture or metastasis.

B. "You should not palpate your child's abdomen prior to surgery.": Avoiding abdominal palpation is crucial because Wilms’ tumors are highly vascular and encapsulated. Palpation could cause rupture, leading to tumor cell spread into the peritoneal cavity and increasing the risk of metastasis.

C. "You should give your child captopril 200 mg PO daily.": Captopril is not a standard medication in the treatment of Wilms’ tumor. It is an antihypertensive that may be used if the child has associated hypertension, but the dosage listed is excessive for pediatric use and should not be prescribed without specific indications.

D. "Your child will not require further treatment after removal of the tumor.": Most children require additional therapy, such as chemotherapy and/or radiation, depending on tumor staging. Surgical removal alone is rarely curative, particularly in advanced or bilateral cases.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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