A nurse is observing an assistive personnel (AP). For which of the following actions by the AP should the nurse intervene?

Logs oﬀ the computer after entering a client's intake and output totals.

Tears a document with client information in half before disposing of it in a waste basket.

Denies a request by another AP to use her password to enter client's vital signs.

Removes a clipboard with client information from the room during visiting hours.

Answer and Explanation

The Correct Answer is B

The nurse should intervene when the AP tears a document with client information in half before disposing of it in a waste basket. This is because client information is confidential and should be disposed of properly to protect the client's privacy. Tearing a document in half is not sufficient to ensure that the information is protected.
Option A is incorrect because logging oﬀ the computer after entering a client's intake and output totals is an appropriate action.
Option C is incorrect because denying a request by another AP to use her password to enter the client's vital signs is an appropriate action to protect the client's information.
Option D is incorrect because removing a clipboard with client information from the room during visiting hours may be necessary to protect the client's privacy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should have the AP perform the task of feeding a school-age client who has burns on both upper extremities first. This task is a high priority because it addresses the client's immediate need for nutrition and hydration. The client's burns may make it difficult for them to feed themselves, so the assistance of the AP is necessary to ensure that the client receives adequate nourishment.

The other tasks are also important, but they are not the highest priority in this situation. Collecting a stool sample for ova and parasites from a toddler [b] and bathing an adolescent client who is disabled [c] are routine tasks that can be performed as time permits. Ambulating a preschooler who is postoperative to the playroom [d] is also important for promoting mobility and recovery, but it is not as urgent as addressing the immediate need for nutrition and hydration.

A. A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. B. A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. C. A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.

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 observing an assistive personnel (AP). For which of the following actions by the AP should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a pediatric unit is working with an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

Correct Answer is A

Explanation

A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

Correct Answer is C

Explanation

A nurse wants to prepare a patient report utilizing SBAR, which she knows is a systematic method of communication. To ensure the report is thorough, what types of information does she need? SELECT ALL THAT APPLY:

A nurse is caring for a client who has dementia and is scheduled for a procedure. Which of the following individuals should the nurse request to sign the client's informed consent?

A charge nurse in an acute care facility receives a client's request not to have particular assistive personnel (AP) care for her. Which of the following actions should the charge nurse take?

When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is:

A nurse tells another nurse that she thinks that he did not provide adequate care for a client who underwent a hip arthroplasty earlier that day. Which of the following responses by the accused nurse demonstrates assertiveness?

The best source of information regarding the roles of the LPN in a med-surg setting is:

When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This is an example of which ethical principle?

A charge nurse in a long-term care facility checks with other nursing personnel on the unit throughout the day to determine if they are completing tasks. Which of the following rights of delegation is the nurse demonstrating?