A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids."
"An AP may count the respirations of a client who is going to have surgery later the same day."
"An AP may take orthostatic blood pressure measurements from a client who reports dizziness."
"An AP may perform a central line dressing change for a client who is ready for discharge."
The Correct Answer is B
A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Do you have difficulty sleeping at night?" – While sleep disturbances are common in PTSD, this question assesses symptoms rather than support systems.
B. "How do you feel about the current status of your life?" – This question may provide insight into the client’s emotional state but does not directly assess their support systems.
C. "Have you noticed changes in your eating patterns?" – Changes in appetite can occur with PTSD, but this question focuses on physical symptoms rather than support systems.
D. "Are you comfortable discussing the disaster with your family or friends?" – This is the best choice because it directly assesses whether the client has a support system in place and feels comfortable relying on them for emotional support.
Correct Answer is A
Explanation
A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.