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 B

Explanation

A. Ensure the client's room is dark at night: A dark room can increase confusion and agitation in clients with dementia, especially at night. It’s important to provide a well-lit environment to reduce confusion and help the client maintain a sense of orientation.
B. Use symbols to assist the client in finding personal items: Using symbols, pictures, or labels to help the client identify personal items can provide orientation and reduce frustration. This approach supports independence while minimizing confusion.
C. Ask the client orientation questions many times per day: Asking orientation questions repeatedly can increase anxiety and confusion for clients with dementia. It’s more effective to provide reassurance and support rather than focusing on constant questioning of orientation.
D. Provide a high level of sensory stimulation during the day: While some level of stimulation is important, excessive sensory input can overwhelm or agitate a client with dementia. The environment should be calm and soothing to avoid overstimulation.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

Rationale:

Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol.
Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention.

Rationale for incorrect choices:

Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis.
Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction.
Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition.
Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.

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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 caring for a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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