A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Pouching a client's ostomy bag for a new colostomy

Performing nasal hygiene for a client who has an NG tube

Measuring oxygen saturation for a client who has dyspnea

Inserting a rectal suppository for a client who is vomiting

Answer and Explanation

The Correct Answer is B

A.   Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B.   Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C.   Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D.   Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.

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Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

A. A client who reports right-sided flank pain and is diaphoretic B. A client who reports shortness of breath and left neck and shoulder pain C. A client who has active bleeding from a puncture wound of the left groin area D. A client who has a raised red skin rash on his arms, neck, and face

Correct Answer is B

Explanation

A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.

B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.

C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.

D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.

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A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

Correct Answer is B

Explanation

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A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

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