After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

42 year old who is due to arrive from the emergency room and has experienced a stroke

43 year old female who is post operative surgery and is bleeding from their wound

82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath

21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Answer and Explanation

The Correct Answer is D

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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Correct Answer is C

Explanation

A. Only at the beginning of the hospital stay to establish a baseline. This is incorrect because while an initial assessment establishes a baseline, ongoing assessments are necessary to monitor changes in the patient’s condition.

B. Once a week during routine rounds. This is incorrect because patient conditions can change rapidly, and weekly assessments are insufficient for monitoring acute care patients.

C. At each shift change to identify any changes in the patient's condition. This is correct because ongoing assessments should be performed regularly, especially at the beginning of each shift. This allows the nurse to detect changes early, adjust care plans, and intervene as needed.

D. Only when the patient reports new symptoms. This is incorrect because waiting for a patient to report symptoms may delay critical interventions. Many conditions, such as sepsis or respiratory distress, can progress without the patient immediately recognizing symptoms. Routine monitoring helps identify early signs of deterioration.

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight B. Caregiver Role Strain, related to depression, as evidenced by constant crying C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain

Correct Answer is C

Explanation

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.

B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.

C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:

Diagnosis: Impaired Skin Integrity

Etiology (related to): Physical immobility

Defining characteristics (as evidenced by): Skin tear over the sacral area

D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."

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After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When should a nurse perform an ongoing assessment during a patient's hospital stay?

Correct Answer is C

Explanation

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Correct Answer is C

Explanation

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