A 73-year-old male patient has been admitted to an inpatient unit from the emergency room. He has been coughing severely for the past two days, has a headache, and a sore throat.

His COVID test is positive and he has Type II Diabetes. He denies any history of smoking.

His vital signs are as follows: Temperature - 101.0, Pulse - 84, Respiration - 24, Blood Pressure - 152/84, Pulse oximetry - 92%. The registered nurse (RN) delegates the collection of a urine specimen and Fasting Blood Sugar (FSBS) from the client to the nurse aide II. What are the responsibilities of the RN in regard to this delegated task?

Select all that apply.

Ensure the nurse aide has the required training to perform these tasks.

Maintain accountability for ensuring the delegated tasks are conducted correctly and completely.

Ensure policies cover the delegation.

Perform an assessment of the patient prior to delegation.

Observe all tasks performed by the nurse aide II.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
This statement is more about describing the specific situation (the “D” in DESC) rather than expressing the nurse’s concerns (the “E” in DESC). It’s important to note that the DESC tool stands for Describe, Express, State, and Consequences. In this context, the nurse is merely stating what happened, not expressing how it made them feel or the impact it had on them.
Choice B rationale
This statement accurately represents the “E” component of the DESC tool, which stands for "Express your concerns"12. In this scenario, the nurse is expressing their feelings about the physician’s behavior and its impact on them. They’re stating how the physician’s actions made them feel uncomfortable, especially in front of other staff members and the patient. This is a crucial step in the DESC process as it allows the individual to express their feelings and concerns about the situation.
Choice C rationale
This statement is more aligned with the “S” component of the DESC tool, which stands for "State other alternatives"12. Here, the nurse is suggesting a different way for the physician to express their concerns in the future. While this is an important part of the DESC process, it does not represent the “E” component.
Choice D rationale
This statement represents the “C” component of the DESC tool, which stands for "Consequences stated"12. In this context, the nurse is outlining the potential outcomes if they cannot agree on an alternative approach. While this is a crucial step in the DESC process, it does not represent the “E” component.

A. Trust. B. Social Support. C. Environmental considerations. D. Dependence.

Correct Answer is B

Explanation

Choice A rationale
While trust is an important aspect of the patient-family relationship, it’s not the primary need being considered in this scenario. The nurse is discussing allowing patient families to visit as often as the patient’s condition will allow. This is more about providing emotional and social support to the patient, rather than building trust.
Choice B rationale
Social support is the primary need being considered in these conversations. Evidence shows that the unrestricted presence and participation of a support person (i.e., family as defined by the patient) can improve the safety of care and enhance patient and family satisfaction. This is especially true in the ICU, where patients are often unable to speak for themselves.
Choice C rationale
While environmental considerations are important in any care setting, they’re not the primary need being considered in this scenario. The nurse is discussing the frequency of family visits, which is more about providing social support to the patient.
Choice D rationale
Dependence is not the primary need being considered in this scenario. The nurse is discussing the frequency of family visits, which is more about providing social support to the patient.
While patients in the ICU may be dependent on medical staff for their physical needs, the presence of family can provide emotional and social support.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An ICU nurse has had many discussions with fellow nursing colleagues about allowing patient families to visit as often as the patient’s condition will allow. Which patient and family need is the nurse considering in these conversations?

Correct Answer is B

Explanation

A nurse is conducting a medication count of narcotics in the cart. The nurse discovers an incorrect count and missing narcotic medication. Which ethical standard compels the nurse to report the missing medication?

A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient’s pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse’s priority action?

The RN is creating assignments for the day. The team includes RNs, LPNs, and Nurse Aides. Which patient is most suitable to assign to the LPN?

Which of the following is an example of indirect care?

When teaching clients about maintaining a safe environment, which statement would be most suitable to include?

The nurse is assessing the apical pulse. Where should the stethoscope be placed?

Which of the following actions is specific to the Health Information Technology for Economic and Clinical Health (HITECH) Act?

A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?