A charge nurse in an acute care facility is teaching a newly licensed nurse about caring for a client who has a cognitive impairment. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will let the client sit at the nurses' station during the day."

"I will assign the client to a room close to the nurses station."

"I will elevate full-length bed rails while the client is in bed."

"I will place a red wristband on the client to indicate fall risk."

Answer and Explanation

The Correct Answer is B

Rationale:

A. This option is incorrect because allowing a client with cognitive impairment to sit at the nurses’ station during the day without supervision can increase risks for wandering, agitation, or injury. Clients with cognitive deficits often have difficulty understanding their environment and may inadvertently interfere with clinical operations or put themselves at risk. Safe, structured, and familiar environments are preferable.

B. This option is correct because placing the client’s room near the nurses’ station allows for closer monitoring and timely intervention if the client becomes confused, attempts to wander, or exhibits behavioral changes. This proximity supports patient safety while still promoting a sense of autonomy and privacy. Nurses can quickly respond to needs or emergencies, which is especially important for clients with cognitive impairment who may not recognize hazards or communicate effectively.

C. This option is incorrect because using full-length bed rails for clients with cognitive impairment is associated with increased risk of entrapment, injury, or falls if the client attempts to climb over them. Safer alternatives include half rails, low beds, or motion-sensor alarms, which protect the client while reducing risk.

D. This option is incorrect because a red wristband indicating fall risk is only a visual cue for staff and does not actively prevent falls. Comprehensive fall prevention requires environmental modifications, frequent monitoring, use of assistive devices, and individualized care plans rather than relying solely on identification bands.

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Correct Answer is A

Explanation

Rationale:

A. This option is correct because measuring and recording a client’s urinary output is within the scope of practice for an assistive personnel (AP). This task is noninvasive, routine, and does not require nursing judgment, making it appropriate for delegation.

B. This option is incorrect because performing a sterile dressing change is a nursing intervention that requires knowledge of aseptic technique, assessment skills, and clinical judgment. It cannot be delegated to an AP.

C. This option is incorrect because instructing a client on the use of crutches involves teaching, assessment of the client’s abilities, and evaluation of safety, all of which are nursing responsibilities and cannot be delegated to an AP.

D. This option is incorrect because interpreting an ECG strip requires specialized nursing knowledge and clinical judgment to identify dysrhythmias and respond appropriately. This is outside the AP’s scope of practice.

A. Document a nurse's note in the client's electronic medical record (EMR). B. Modify the client's plan of care. C. Document this as a negative variance in the critical pathway. D. Discontinue critical pathway. E. Initiate discharge summary documentation.

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

Explanation

Rationale:

A. This option is correct because all significant changes in the client’s condition, including the sudden deterioration and intubation, must be documented accurately in the EMR. Thorough documentation ensures continuity of care, legal protection, and communication among the interprofessional team.

B. This option is correct because the client’s sudden deterioration and need for mechanical ventilation require immediate revision of the care plan. Updates should include new interventions, monitoring requirements, and goals relevant to the client’s current status, ensuring safe and appropriate care.

C. This option is correct because a negative variance occurs when the client’s actual progress deviates from the expected outcomes outlined in the critical pathway. The client’s sudden respiratory failure represents a deviation that should be recorded to guide future care planning and quality improvement.

D. This option is incorrect because the critical pathway should not be discontinued; it remains a guide for expected outcomes. Instead, variances should be documented, and the pathway adjusted as appropriate.

E. This option is incorrect because the client is acutely unstable and requires ongoing intensive care. Discharge summary documentation is premature and not relevant at this point.

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A charge nurse in an acute care facility is teaching a newly licensed nurse about caring for a client who has a cognitive impairment. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is A

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

Explanation

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