A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

Is the client's family present so the AP can show them how to turn the client?

Has the AP checked the client's pain level prior to turning her?

Does the AP have time to change the client's central IV line dressing after turning her?

Has data been collected about specific client needs related to turning?

Answer and Explanation

The Correct Answer is D

A.   While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B.   Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C.   Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D.   Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

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Correct Answer is A

Explanation

A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.

A. Inform the unit manager of the incident. B. Speak with the AP about the incident. C. Remove the restraints from the client's wrists. D. Review the chart for nonrestraint alternatives for agitation,

Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?

Correct Answer is A

Explanation

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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