A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Encourage fluid intake.

Continue to monitor vital signs.

Notify the primary health care provider.

Monitor the site of the shunt for infection.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging fluid intake is inappropriate post-hemodialysis, as fluid overload is a risk. A fever of 101.2°F requires provider notification, making this incorrect, as it’s unsafe compared to the nurse’s priority of addressing a potential infection promptly.

Choice B reason: Monitoring vital signs is useful but doesn’t address the urgency of a 101.2°F fever post-hemodialysis, which may indicate infection. Notifying the provider is critical, making this incorrect, as it delays the nurse’s action to manage a serious complication.

Choice C reason: Notifying the provider is most appropriate for a fever of 101.2°F post-hemodialysis, as it may signal infection, a serious complication. This aligns with post-dialysis care priorities, making it the correct action for the nurse to take immediately.

Choice D reason: Monitoring the shunt site is relevant but less urgent than notifying the provider about a fever, which may indicate systemic infection. This is incorrect, as it delays the nurse’s priority of addressing the client’s elevated temperature post-hemodialysis.

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Correct Answer is C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

A. Asking the LPN to administer an intramuscular injection to a patient. B. Asking the LPN to assess a post-operative patient’s wound for signs of infection. C. Asking the MA to complete a follow-up call with a patient about test results. D. Asking the MA to insert a nasogastric tube in a patient who requires nutritional support.

Correct Answer is A

Explanation

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

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A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

You are working on a busy unit and need to delegate tasks to the LPN and M

Correct Answer is A

Explanation

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