The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first plan to
dropdown
and then
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale:

• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.

• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.

• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.

• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.

• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.

• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.

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Correct Answer is A

Explanation

Rationale:

A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.

B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.

C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.

D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.

A. Reinforce client teaching about walking with crutches B. Plan care for a client who has dysphagia. C. Transfer a client who is receiving radiation therapy to radiology D. Record urine output for a client who has a suprapubic catheter E. Measure vital signs for a client who requires contact precautions.

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

Explanation

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.

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The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data. Exhibits Complete the following sentence by using the list of options. The nurse should first plan to dropdown and then dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

Correct Answer is A

Explanation

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply)

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

Explanation

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. "Why is colostrum so important for baby?" Which of the following responses should the nurse make?

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath. and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first plan to
dropdown
and then
dropdown
.