The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

The unlicensed assistive personnel tied the confused client to a chair with a sheet.

The unlicensed assistive personnel escorted the client downstairs to smoke a cigarette.

The unlicensed assistive personnel assisted the client in ambulating to the dayroom area.

The unlicensed assistive personnel bought the client a carbonated beverage from the cafeteria.

Answer and Explanation

The Correct Answer is A

This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.

Choice A rationale

Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.

Choice B rationale

While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.

Choice C rationale

Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.

Choice D rationale

Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.

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Free Nursing Study Resources

Correct Answer is ["7"]

Explanation

Step 1 is 350 mg ÷ 250 mg × 5 mL.

Step 2 is 1.4 × 5 mL.

Step 3 is 7 mL.

A. To prevent syndrome of inappropriate antidiuretic hormone. B. Vasopressin replaces antidiuretic hormone normally secreted by the pituitary. C. Vasopressin reduces cerebral edema and lowers intracranial pressure. D. The medication is administered IM to treat growth failure.

Correct Answer is B

Explanation

A hypophysectomy involves the surgical removal of the pituitary gland. Knowledge of endocrine physiology is required to understand the postoperative loss of posterior pituitary hormones and the necessity of exogenous replacement therapy to maintain fluid balance and prevent complications.

Choice A rationale

Syndrome of inappropriate antidiuretic hormone involves excessive ADH, whereas hypophysectomy results in a total deficiency. Vasopressin is given to prevent the opposite condition, diabetes insipidus, characterized by massive polyuria and severe fluid volume deficit.

Choice B rationale

The posterior pituitary stores and secretes antidiuretic hormone (ADH), also known as vasopressin. Removal of the gland eliminates the body's ability to concentrate urine, necessitating hormonal replacement to regulate water reabsorption in the kidneys.

Choice C rationale

Vasopressin is not primarily used to treat cerebral edema or intracranial pressure. While it affects fluid volume, medications like mannitol or corticosteroids are the standard pharmacological interventions for managing postoperative cerebral swelling and elevated pressure.

Choice D rationale

Vasopressin is an antidiuretic hormone, not a growth hormone. Growth failure is treated with somatropin. While pituitary removal stops growth hormone production, the immediate life-threatening concern postoperatively is the management of massive water loss.

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit. Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? Round to the nearest whole number.

Correct Answer is ["7"]

Explanation

The new graduate nurse asks the experienced nurse, Why does a client receive vasopressin after undergoing a hypophysectomy? How should the nurse respond?

Correct Answer is B

Explanation

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?