A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Wash the tablet off with alcohol and place it in a clean medication.

Use the tablet's packaging to pick it up from the counter.

Discard the tablet and obtain another dose of medication.

Place the tablet directly into a medication cup.

Answer and Explanation

The Correct Answer is C

A.   Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B.   Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C.   Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D.   Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.

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Correct Answer is ["A","C","D"]

Explanation

Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.

Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.

Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.

Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.

Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.

A. He is hard of hearing. B. Confusion C. Pain D. Language barrier E. None F. None

Correct Answer is B

Explanation

A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.

B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.

C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.

D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor

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A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is B

Explanation

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