The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task?
The nurse should review the patient's vital signs as soon as they are done.
The nurse assistant should not be responsible for obtaining vital signs.
The nurse is not responsible if the nurse assistant fails to obtain the vital signs.
The nurse assistant should determine if the patient's vital signs are abnormal.
The Correct Answer is A
A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
Correct Answer is D
Explanation
A. 4+. A 4+ pulse is bounding and strong, often seen in conditions like fever, anemia, or fluid overload. This does not match the description of a weak pulse.
B. 3+. A 3+ pulse is stronger than normal but not bounding. This is not considered weak.
C. 2+. A 2+ pulse is normal and easily palpable, which does not indicate the weakened pulse described in the patient.
D. 1+. A 1+ pulse is weak and thready, meaning it is difficult to palpate and easily disappears with slight pressure. This grading is appropriate for a hypotensive patient with poor perfusion.
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