The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Determine the need for urinary catheterization

Titrate oxygen to prescribed parameters.

Receive a postoperative client and conduct the assessment.

Evaluate and update plans of care for clients.

Answer and Explanation

The Correct Answer is B

Choice A: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.

Choice B: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.

Choice C: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.

Choice D: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.

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Correct Answer is D

Explanation

Choice A: Administering a half dose now is not a safe instruction for the nurse to provide, as this can result in overdosing or underdosing the infant, depending on how much of the medicine was absorbed or expelled. This is a contraindicated choice.

Choice B: Giving another dose is not a prudent instruction for the nurse to provide, as this can cause digoxin toxicity, which can be life-threatening for the infant. This is another contraindicated choice.

Choice C: Mixing the next dose with food is not a relevant instruction for the nurse to provide, as this does not address the current situation and can affect the absorption and effectiveness of digoxin. This is a distractor choice.

Choice D: Withholding this dose is a sensible instruction for the nurse to provide, as this can prevent adverse effects and allow the infant's serum digoxin level to be checked before giving another dose. Therefore, this is the correct choice.

A. Maintain a quiet, non-stimulating environment. B. Force oral fluids and provide frequent small meals. C. Confront the client's denial of substance abuse. D. Encourage attendance and group participation.

Correct Answer is A

Explanation

Choice B reason: Forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. Although hydration and nutrition are important to prevent dehydration and electrolyte imbalance, they are not the priority in this case. The client may have difficulty swallowing, vomiting, or aspiration due to altered mental status.

Choice C reason: Confronting the client's denial of substance abuse is not an appropriate intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or respond rationally to such confrontation due to impaired cognition and perception. The nurse should avoid arguing or challenging the client's beliefs and focus on providing safety and comfort.

Choice D reason: Encouraging attendance and group participation is not a feasible intervention for a client with alcohol withdrawal delirium. The client may not be able to participate in any social or educational activities due to severe withdrawal symptoms and delusions. The nurse should limit visitors and stimuli and provide one-to-one supervision and reassurance.

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The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is D

Explanation

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Correct Answer is A

Explanation

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