A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?

Administering a subcutaneous insulin injection

Collecting a sputum culture

Providing discharge teaching about home IV medication therapy

Removing an NG tube

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Providing discharge teaching about home IV medication therapy.

Choice A rationale:

Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.

Choice B rationale:

Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.

Choice C rationale:

Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.

Choice D rationale:

Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.

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Correct Answer is A

Explanation

The correct answer is A. Clean the wound from the center to the outer edges.

Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.

The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.

A. "Let's take a walk outside to see if the voices you are hearing will stop." B. "Can you listen to me instead of the voices you are hearing?" C. "Are the voices you are hearing telling you to hurt yourself or someone else?" D. "I know that the voices are real to you, but I do not hear them."

Correct Answer is C

Explanation

The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.

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A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Correct Answer is A

Explanation

A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching?

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