A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)

Ambulate a client who has a cane.

Demonstrate the technique to instill eye drops.

Record urinary output.

Irrigate a wound.

Transfer a client to a stretcher.

Answer and Explanation

Correct Answer : A,C,E

A. Ambulate a client who has a cane: Ambulating a stable client is a standard skill (ADL) that does not require nursing assessment.

B. Demonstrate the technique to instill eye drops: "Demonstrating" implies teaching. Teaching and evaluating learning are the exclusive responsibilities of the RN and cannot be delegated to an AP.

C. Record urinary output: Assistive Personnel can collect data (measure volume) and record it. The RN then analyzes that data (assessment).

D. Irrigate a wound: Wound irrigation is a sterile or clean procedure that requires assessment of the wound bed and skin integrity. This is a nursing skill.

E. Transfer a client to a stretcher: Transfers and mobility assistance are standard skills within the AP's scope of practice, provided the client is stable.

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Correct Answer is A

Explanation

A. Neuroleptic malignant syndrome:NMS is a rare but life-threatening reaction to antipsychotic medications (like haloperidol). The classic triad of symptoms includes hyperpyrexia(very high fever, e.g., 103.4° F), severe muscle rigidity(lead pipe rigidity), and autonomic instability(fluctuating BP, tachycardia). This requires immediate discontinuation of the drug and intensive care.

B. Akathisia:Akathisia is an extrapyramidal side effect (EPS) characterized by internal restlessness and an inability to sit still. It does not cause high fever or severe autonomic instability.

C. Tardive dyskinesia:This is a long-term side effect of antipsychotics involving involuntary, repetitive movements of the face (lip-smacking, tongue protruding) and limbs. It is not an acute emergency involving fever.

D. Agranulocytosis:This is a dangerous drop in white blood cells (neutrophils), commonly associated with Clozapine, not Haloperidol. It presents with signs of infection (sore throat, fever), but not muscle rigidity or hypertension.

A. "Clients who have glaucoma should not take warfarin." B. "Clients who are pregnant should not take warfarin." C. "Clients who have hyperthyroidism should not take warfarin." D. "Clients who have rheumatoid arthritis should not take warfarin."

Correct Answer is B

Explanation

A. "Clients who have glaucoma should not take warfarin." Glaucoma is not a contraindication for warfarin. Warfarin affects clotting factors, not intraocular pressure.

B. "Clients who are pregnant should not take warfarin." Warfarin (Coumadin) is a teratogen(Pregnancy Category X). It crosses the placenta and can cause fetal hemorrhage, spontaneous abortion, and severe congenital defects (fetal warfarin syndrome). Pregnant clients requiring anticoagulation are typically switched to Heparin or Enoxaparin (Lovenox), which do not cross the placenta.

C. "Clients who have hyperthyroidism should not take warfarin." While hyperthyroidism can increase the metabolism of clotting factors (potentially increasing the INR response), it is not a contraindication. The dose just needs to be monitored and adjusted closely.

D. "Clients who have rheumatoid arthritis should not take warfarin." Rheumatoid arthritis itself is not a contraindication. However, the nurse should warn the client about interacting medications often used for RA (like NSAIDs), which increase bleeding risk.

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A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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