A nurse on a medical-surgical unit has just received a change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel?

Showing a client who has a new colostomy how to empty the pouch.

Reinserting an NG tube for a client who requires gastric decompression

Performing a closed catheter irrigation for a client who is postoperative

Bathing a client who has hemiparesis following a stroke

Answer and Explanation

The Correct Answer is D

A.   Showing a client who has a new colostomy how to empty the pouch. Client education requires the clinical knowledge and teaching skills of a nurse.
B.   Re-inserting an NG tube for a client who requires gastric decompression. NG tube insertion is a skilled task that requires clinical assessment and monitoring by a nurse.
C.   Performing a closed catheter irrigation for a client who is postoperative. Closed catheter irrigation requires sterile technique and clinical judgment, which are nursing responsibilities.
D.   Bathing a client who has hemiparesis following a stroke. APs can assist with bathing and hygiene tasks.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Client 1 (First Priority):

Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Asking a staff member from another unit to complete the evaluation B. Linking the evaluation to predetermined standards C. Focusing primarily on areas that need improvement D. Discussing the evaluation with the nurse manager

Correct Answer is B

Explanation

A. Asking a staff member from another unit to complete the evaluation: Staff from other units may not have direct knowledge of the nurse's work performance.
B. Linking the evaluation to predetermined standards: Using predetermined standards ensures objectivity and consistency in evaluations.
C. Focusing primarily on areas that need improvement: Evaluations should be balanced, recognizing both strengths and areas for improvement.
D. Discussing the evaluation with the nurse manager: The evaluation should first be completed independently before discussing it with a manager if needed.

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A nurse on a medical-surgical unit has just received a change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel?

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Naxlex Comprehensive Predictor Exams

A charge nurse on a mental health unit is receiving a change of shift report for a group of clients. Exhibits Complete the following sentence by using the lists of options. The nurse should first collect data from dropdowndue to dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

A nurse is completing a peer evaluation. Which of the following actions will ensure the peer evaluation is impartial?

Correct Answer is B

Explanation

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