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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Calculation:
Desired dose = 60 mg.
Available concentration = 50 mg/1.25 mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 60 mg / (50 mg / 1.25 mL)
= 60 mg / 40 mg/mL
= 1.5 mL.
Correct Answer is A
Explanation
Rationale:
A. Encourage client to swallow while advancing tube: Swallowing facilitates the passage of the nasogastric tube through the oropharynx and esophagus by closing the epiglottis and reducing the risk of the tube entering the trachea. This action helps guide the tube smoothly into the stomach.
B. Measure the length of the tube from client's nose to shoulder: Proper measurement involves extending the tube from the nose to the earlobe and then down to the xiphoid process, not just to the shoulder.
C. Place client in semi-Fowler's position in bed: The client should be placed in a high-Fowler’s position, not semi-Fowler’s, to promote comfort and reduce the risk of aspiration. This upright position also allows for easier passage of the tube through the upper GI tract.
D. Advance tube during client's inspiration: Advancing the tube during inspiration increases the risk of the tube entering the airway rather than the esophagus. The tube should be advanced when the client is swallowing, which helps direct it into the digestive rather than respiratory tract.
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