A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Accompany a client who has depression to occupational therapy.

Initiate soft wrist restraints on a client who is at risk for self-harm.

Sit with a client who has alcohol use disorder and whose last drink was five days ago.

Set limits with a client who has mania.

Work a jigsaw puzzle with a client who has dementia.

Assess a client who has hypomania for exhaustion.

Answer and Explanation

Correct Answer : A,E

A.   This is a routine task that can be safely delegated to a NAP. It does not require complex decision- making or assessment skills.
B.   This task requires the ability to assess the client's condition and determine the appropriate level of restraint. It is a task that should be performed by an RN or licensed practical nurse (LPN).
C.   While this may seem like a simple task, it requires the ability to monitor the client for signs of withdrawal and to intervene if necessary. It is a task that should be performed by an RN or LPN.
D.   This task requires the ability to assess the client's behavior and to intervene if necessary. It is a task that should be performed by an RN or LPN.
E.   This is a therapeutic activity that can be delegated to a NAP. It can help to stimulate the client's cognitive function and provide social interaction.
F.   This task requires the ability to assess the client's condition and identify potential complications. It is a task that should be performed by an RN or LPN.

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Correct Answer is C

Explanation

A. While this situation raises ethical considerations, particularly regarding adolescent confidentiality, the nurse is not justified in overriding the client's right to confidentiality solely based on the request. In many jurisdictions, minors may have the right to confidentiality about reproductive health issues, though this can vary.
B. The nurse is generally required to respect this client's confidentiality. Unless there is a specific safety concern (e.g., domestic violence), the nurse should honor the client's request to keep this information private. Confidentiality should be upheld unless there is a clear and immediate risk of harm.
C. In this situation, the nurse may be justified in overriding the client’s confidentiality due to the disclosure of potential abuse. Healthcare professionals are often mandated reporters in cases of suspected abuse or neglect, particularly involving vulnerable populations such as older adults. The nurse has a duty to report this situation to ensure the safety of the client.
D. A client's wish not to know their diagnostic results does not justify overriding their confidentiality. The nurse must respect the client’s autonomy and decision-making regarding their own health information. The nurse should provide support and discuss the implications of this decision but should not disclose the results without the client’s consent.

A. Call the provider for a stat DNR order. B. Seek immediate help from the risk manager. C. Respect the family's wishes and do nothing. D. Call the emergency response team.

Correct Answer is D

Explanation

A. While it's important to obtain a formal DNR order, the nurse should not delay providing emergency care while waiting for the order. The client's immediate needs take precedence.
B. The risk manager can provide guidance and support, but they cannot provide immediate medical care. The nurse's priority should be to provide emergency care to the client.
C. Even in the absence of a formal DNR order, the nurse has a legal and ethical duty to provide emergency care to a client who is in cardiac or respiratory arrest.
D. This is the most appropriate action. The nurse should immediately call the emergency response team to initiate resuscitation efforts. While waiting for the team to arrive, the nurse should continue to provide basic life support measures, such as CPR and rescue breathing. Once the emergency response team arrives, they will take over the resuscitation efforts and obtain a formal DNR order from the provider if necessary.

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A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which situation would the nurse be justified in overriding a client's right to confidentiality?

Correct Answer is C

Explanation

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not- resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse at a community clinic is reinforcing education for a newly licensed nurse about nursing advocacy. Which of the following actions should the nurse include as an example of nursing advocacy?

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?

A client with frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN?

The care of a client is assigned to a newly-graduated RN. What actions can the newly-graduated RN delegate to the unlicensed assistive personnel (UAP)? [SELECT ALL THAT APPLY]

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

The RN overbears the nurses' aide speaking in a harsh tone to a client with early Alzheimer's memory loss. Which statement should the EN make to begin addressing this issue?