The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Performing chest percussion on a client with atelectasis

Auscultate lungs on a client with audible wheezing

Taking vital signs on a male client with severe dyspnea

Suctioning a client with hemoptysis (bloody sputum)

Setting up a meal tray for a client with COPD

Answer and Explanation

The Correct Answer is E

A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.

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Correct Answer is ["A","C"]

Explanation

A. Pulmonic valve closure is best heard at the base of the heart, near the second intercostal space at the left sternal border.
B. Tricuspid valve sounds are best heard at the lower left sternal border, near the apex rather than the base of the heart.
C. Aortic valve closure is also best heard at the base of the heart, near the second intercostal space on the right sternal border.
D. Mitral valve sounds are heard best at the apex of the heart, near the fifth intercostal space in the midclavicular line, not the base.

A. Have client use the incentive spirometer every hour B. Help client dangle legs off the side of the bed C. Encourage the client to ambulate as soon as possible D. Keep the client in bed with knees elevated E. Limit the amount of fluid the client drinks

Correct Answer is B

Explanation

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When listening to heart sounds, which valve closures are heard best at the base of the heart. Select all that apply.

Correct Answer is ["A","C"]

Explanation

The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Correct Answer is B

Explanation

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