A nurse receives care assignments for a group of clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? (Select all that apply.)

Applying a vacuum-assisted wound closure device on a client's pressure ulcer

Developing a plan of care for a newly admitted client

Preparing a teaching plan for a client who has a new prescription for insulin

Obtaining a client's post-void residual using a bladder scanner

Initiating the administration of a blood transfusion for a client

Answer and Explanation

Correct Answer : A,B,C,E

A.   Applying a vacuum-assisted wound closure device on a client's pressure ulcer: This task requires clinical judgment and advanced training, which are appropriate for an RN.
B.   Developing a plan of care for a newly admitted client: Creating care plans requires comprehensive assessment and clinical decision-making, which are within the RN's scope.
C.   Preparing a teaching plan for a client who has a new prescription for insulin: Teaching requires advanced knowledge to assess learning needs and provide education.
D.   Obtaining a client's post-void residual using a bladder scanner: This task is within the scope of practice for assistive personnel (AP) if trained.
E.   Initiating the administration of a blood transfusion for a client: Blood transfusion initiation requires close monitoring and assessment for adverse reactions, which falls under the RN's scope.

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Correct Answer is ["B","C","D","E","F"]

Explanation

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

A. Close the door to the client's room. B. Activate the alarm outside the client's room. C. Use a Class A fire extinguisher to contain the fire. D. Turn off electrical equipment in the client's room.

Correct Answer is B

Explanation

A. Close the door to the client's room: This helps contain the fire and prevents smoke from spreading, but it should not be the immediate action after client removal.
B. Activate the alarm outside the client's room: Activating the alarm is critical after ensuring the client's safety, as it alerts the facility to the emergency and mobilizes response teams.
C. Use a Class A fire extinguisher to contain the fire: The type of extinguisher used depends on the fire classification. Attempting to extinguish a fire should occur only after the alarm is activated.
D. Turn off electrical equipment in the client's room: While turning off electrical equipment can reduce fire hazards, it is not the next priority after removing the client.

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A nurse receives care assignments for a group of clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client. Exhibits The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

Correct Answer is B

Explanation

A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

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A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

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