A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

The task involves making ongoing judgments about client data.

The task is within the AP’s range of function to perform.

The task can be performed in the same manner for most clients.

The task requires a specific sequence of steps.

Answer and Explanation

The Correct Answer is A

The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.

Choice B is wrong because the task is within the AP’s range of function to perform.

This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.

Choice C is wrong because the task can be performed in the same manner for most clients.

This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.

Choice D is wrong because the task requires a specific sequence of steps.

This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.

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 B

Explanation

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

A. Place the newborn on their abdomen and observe the movement of their extremities. B. Stroke the newborn’s cheek toward their mouth. C. Stroke upward on the lateral aspect of the newborn’s foot. D. Place the newborn on a flat surface and clap hands loudly.

Correct Answer is D

Explanation

Place the newborn on a flat surface and clap hands loudly.

This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.

Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.

This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.

Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.

Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.

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 reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

Correct Answer is B

Explanation

A nurse is checking a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is D

Explanation

A nurse is collecting data from an adolescent client who takes digoxin. The nurse should monitor the client for which of the following adverse effects?

A nurse is reinforcing teaching about HbA1c with a client who has type 1 diabetes mellitus. Which of the following information should the nurse include?

A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?

A nurse is selecting foods for a client who is in the manic phase of bipolar disorder. Which of the following foods should the nurse offer the client?

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

A nurse is administering the inactivated influenza vaccine to a group of clients at a health clinic. The nurse should recognize that which of the following conditions is a contraindication for this vaccine?

A nurse is collecting data from a client who has recently stopped smoking. Which of the following findings should the nurse recognize as a manifestation of acute nicotine withdrawal?

A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?