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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.

B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.

C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.

D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.

A. Performing a mini mental status exam at admission and discharge B. Performing serial Glasgow Coma Scale exams during hospitalization C. Assessing pupils for reactivity, equality, symmetry and accommodation D. Obtaining vital signs every four hours while hospitalized

Correct Answer is B

Explanation

A. Mini mental status exam at admission and discharge

Useful for cognitive function but not for acute changes.

B. Performing serial Glasgow Coma Scale exams

The GCS is the best tool for tracking changes in neurologic status over time.

C. Assessing pupils for reactivity, equality, symmetry, and accommodation

Important but not comprehensive.

D. Obtaining vital signs every four hours

Useful but does not specifically assess neurologic function.

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Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

Correct Answer is C

Explanation

The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

Correct Answer is B

Explanation

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What action priority in preventing anaphylactic shock?

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

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