The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

Assist the client to take the beta-blocker.

Transport the client to the intensive care unit via a stretcher

Provide the client going home discharge-teaching instructions

Help position the client who is having a portable x-ray done

Answer and Explanation

The Correct Answer is D

Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.

Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.

Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.

Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment of the client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.

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Correct Answer is D

Explanation

Hydrochlorothiazide is a diuretic medication commonly prescribed for hypertension. It works by increasing urine output, which helps to reduce ﬂuid volume and lower blood pressure. Taking the medication in the morning is beneﬁcial because the increased urine production during the day can help prevent nighttime disruptions due to frequent urination.

Let's go through the other statements and explain why they are not accurate:

"I will not take this medicine when my blood pressure is okay":

This statement indicates a misunderstanding about the purpose of hydrochlorothiazide. It is important to take prescribed medications consistently, even when blood pressure readings are within the normal range, as they are intended to help maintain blood pressure control.

"I will check blood pressure in both arms and legs before taking the drug":

Checking blood pressure in both arms and legs is not directly related to hydrochlorothiazide use. Blood pressure should be monitored regularly, but it is not necessary to perform these measurements speciﬁcally before taking the medication.

"I will decrease potassium foods such as bananas in my diet":

Hydrochlorothiazide can cause potassium loss as a side effect. However, reducing potassium-rich foods without healthcare provider guidance may not be appropriate. It is important for the client to discuss dietary adjustments and potassium supplementation with their healthcare provider if needed.

A. Pacer spikes are adequate in number. B. Pacer spikes occur directly before the P waves. C. Pacer spikes occur directly before the QRS waves. D. Pacer spikes occur on the T waves. E. The heart rate is within programmed parameters.

Correct Answer is ["D","E"]

Explanation

The traces that should require immediate follow-up by the nurse are:

● Pacer spikes occur directly before the T waves.

Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.

● The heart rate is outside of programmed parameters.

If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.

Let's review the other options and explain why they do not require immediate follow-up:

Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.

Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.

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The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a hypertensive client who is taking hydrochlorothiazide. What client statement indicates understanding about hydrochlorothiazide?

Correct Answer is D

Explanation

The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Correct Answer is ["D","E"]

Explanation

The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

The nurse is providing discharge education to a client who recently have insertion of a pacemaker/ICD. Which statement by the client should require further follow up by the nurse?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

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The nurse is admitting a client with Abdominal aortic aneurysm. Which assessment data would support the diagnosis?

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?