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Which four of the patient orders can be delegated to the nursing aide? Select all four that apply.

Insert indwelling urinary catheter.

Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr.

Empty urinary catheter and measure the output.

Collect a stool sample for occult blood testing.

Daily weights.

Notify the MD of any signs of bleeding.

Vital signs every 4 hours.

Answer and Explanation

Correct Answer : C,D,E,G

Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.

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

Explanation

Choice A reason: Sedatives and opioids are known to cause delirium, especially in older adults or those with compromised health. These medications can affect the central nervous system, leading to confusion and cognitive impairment.
Choice B reason: Alcohol use, particularly in combination with withdrawal, can lead to delirium. Alcohol affects neurotransmitter function and can cause significant changes in mental status when consumed in excess or withdrawn abruptly.
Choice C reason: Untreated pain can contribute to delirium, particularly in patients who are already vulnerable due to age or underlying health conditions. Pain can cause significant stress on the body and mind, leading to confusion and cognitive dysfunction.
Choice D reason: Sleep deprivation is a significant factor in the development of delirium. Lack of sleep can impair cognitive function and increase the risk of delirium, especially in hospitalized patients or those with pre-existing cognitive impairments.
Choice E reason: Sensory overload, such as exposure to loud noises, bright lights, or unfamiliar environments, can contribute to delirium. Patients with sensory impairments or those in unfamiliar settings are particularly at risk.

A. Patient's blood pressure is 148/84 mm Hg. B. Patient has not been taking the prescribed vitamin D. C. Patient stopped taking the prednisone abruptly 2 days ago. D. Patient has bilateral 2+ pitting ankle edema.

Correct Answer is C

Explanation

Choice A reason: An elevated blood pressure of 148/84 mm Hg is significant and could be related to prednisone use, as corticosteroids can increase blood pressure. However, this finding alone is not as urgent as the abrupt cessation of prednisone, which can lead to adrenal insufficiency and other serious complications.
Choice B reason: Not taking prescribed vitamin D is important, especially in long-term corticosteroid therapy, as vitamin D helps mitigate the risk of bone density loss. However, this issue is not as immediately critical as abruptly stopping prednisone.
Choice C reason: Stopping prednisone abruptly after taking it for 3 weeks is critical information that must be reported to the healthcare provider immediately. Prednisone is a corticosteroid that suppresses the adrenal glands' ability to produce natural steroids. Abrupt discontinuation can lead to adrenal insufficiency, which can be life-threatening. Symptoms of adrenal insufficiency include severe fatigue, weakness, body aches, low blood pressure, and potential shock. Gradual tapering is required to allow the adrenal glands to recover and resume natural steroid production.
Choice D reason: Bilateral 2+ pitting ankle edema is a notable finding and may indicate fluid retention, which can be a side effect of prednisone. While it is important and requires monitoring, it does not carry the same immediate risk as the abrupt cessation of the medication.

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Which four of the patient orders can be delegated to the nursing aide? Select all four that apply.

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Naxlex Comprehensive Predictor Exams

Causative factors for the development of delirium include which of the following? Select all that apply.

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

Explanation

Which information obtained by the nurse in the clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

Correct Answer is C

Explanation

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