A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Transfer a client who has delirium from a bed to a wheelchair.

Inform a client who has schizophrenia about available community services.

Obtain a list of current medications from a client who is experiencing a manic episode.

Insert an NG tube for a client who has acetaminophen toxicity.

Answer and Explanation

The Correct Answer is A

A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.

B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.

C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.

D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.

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Correct Answer is C

Explanation

A. Venlafaxine and frequent yawning/weight loss: Frequent yawning and weight loss are not typical signs of an adverse reaction to venlafaxine. These symptoms can occur with various conditions, but they do not necessarily require withholding the medication.
B. Olanzapine and frequent urination: Frequent urination is not a known side effect of olanzapine. However, the nurse should assess the client for other factors contributing to this symptom. It may not be severe enough to require withholding the medication without further evaluation.
C. Fluoxetine and muscle rigidity/tachycardia: Muscle rigidity and tachycardia could indicate serotonin syndrome, a potentially life-threatening condition. This requires immediate intervention, and the medication should be withheld while notifying the provider for further evaluation and treatment.
D. Nortriptyline and nausea/dry mouth: Nausea and dry mouth are common side effects of tricyclic antidepressants like nortriptyline. These symptoms typically do not require withholding the medication, but the nurse should monitor the client for any worsening or additional adverse effects.

A. Traumatic flashbacks B. Clang associations C. Difficulty finding words D. Revenge seeking behaviour

Correct Answer is C

Explanation

A. Traumatic flashbacks: Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), not dementia. Clients with dementia may experience confusion or memory loss but not typically flashbacks.

B. Clang associations: Clang associations, which involve the use of rhyming words or sounds that are not connected in meaning, are more common in conditions like schizophrenia, not dementia.

C. Difficulty finding words: Difficulty finding words (aphasia) is a common symptom of dementia. As the condition progresses, clients often experience challenges with communication, including word-finding difficulties and trouble with speech.

D. Revenge seeking behavior: Revenge-seeking behavior is not a typical characteristic of dementia. While individuals with dementia may become agitated or exhibit behavioral changes, these are usually related to confusion or frustration, not planned revenge.

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A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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