Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.

A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.

A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.

An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.

Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.

Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.

Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason: This is not the first action because it does not address the safety risk of smoking in the hospital. The nurse should document the occurrence after taking appropriate measures to prevent fire and injury.

Choice B Reason: This is not the first action because it does not stop the client from smoking in the bathroom. The nurse should obtain a prescription for a nicotine patch if the client agrees to quit smoking, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not ensure that the client will comply with the hospital smoking policy. The nurse should educate the client about the health hazards of smoking and the hospital rules, but this can be done later.

Choice D Reason: This is the best action because it alerts the authority figure who can intervene and enforce the hospital smoking policy. The nurse should notify the charge nurse as soon as possible to prevent fire and injury.

A. Offer to assist the client with meal preparation and feeding. B. Thicken the client's liquids if aspiration seems likely. C. Listen to the client's breath sounds before and after meals. D. Assist the client in selecting high protein foods on the menu.

Correct Answer is A

Explanation

Choice A Reason: This is the best action because it helps the client meet their nutritional needs and prevents further weight loss. The nurse should delegate tasks that are within the scope of practice of the UAP, such as feeding assistance.

Choice B Reason: This is not an appropriate action because it requires a nursing assessment and intervention. The nurse should determine if the client is at risk for aspiration and consult with a speech therapist or dietitian before modifying the client's diet.

Choice C Reason: This is not a relevant action because it does not address the nursing problem of altered nutrition. The nurse should monitor the client's respiratory status and oxygenation, but this is not a task that can be delegated to the UAP.

Choice D Reason: This is not a sufficient action because it does not ensure that the client will consume enough food. The nurse should educate the client on the importance of high-protein foods, but this is not a task that can be delegated to the UAP.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?

Correct Answer is D

Explanation

The nurse determines that an elderly client with pneumonia has a nursing problem of "altered nutrition, less than body requirements." Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?

Correct Answer is A

Explanation

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

The nurse determines that an IV vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will

The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?