Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?
Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
With one other CNA logroll a client who has had a bicycle accident
Obtain a weight on a newly admitted client with diabetes
Assist a client to the bathroom 1 hour after a lumbar puncture
The Correct Answer is C
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.
B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.
C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.
D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.
Correct Answer is ["C","E","F"]
Explanation
A. The correct rate is 6 mL/hr
The correct calculation should be verified.
B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K
Protamine sulfate, not vitamin K, is the antidote for heparin.
C. The nurses will complete an event report due to the medication error
A medication error must be reported.
D. Nurse A will document about the event report in the patient’s EMR
Incident reports are internal documents and should not be documented in the EMR.
E. The patient has received a dose of heparin over the prescribed amount
Due to the increased concentration, the patient received more heparin than intended.
F. The patient has received 3200 units of heparin from 1700-1900.
This calculation confirms overdosing.
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