A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Obtain a routine urine sample from a newly-admitted client.

Pass fresh water to clients on the unit.

Transport a client to the radiology department for an x-ray.

Take an arterial blood gas (ABG) specimen to the laboratory.

Answer and Explanation

The Correct Answer is D

Choice A reason: Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive.

Choice B reason: Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed.

Choice C reason: Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status.

Choice D reason: Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.

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Correct Answer is C

Explanation

Choice A reason: While touch can be used to convey interest and warmth, it is essential to recognize that its appropriateness varies among individuals, especially those with psychiatric disorders. The focus should be on understanding the client's comfort level with touch.

Choice B reason: Combining touch with empathy can be beneficial in some cases, but it may not always be appropriate for clients with psychiatric disorders. The individual's perception and comfort with touch should be taken into account before using it as a therapeutic tool.

Choice C reason: This statement acknowledges that touch can have different meanings for different individuals. It emphasizes the need for sensitivity and awareness of the client's personal boundaries and preferences, which is crucial in therapeutic communication with clients diagnosed with psychiatric disorders.

Choice D reason: Touch is not typically used as a primary method for deescalating volatile situations. Non-verbal cues and verbal communication techniques are often more effective and safer methods for managing such scenarios.

A. A client admitted with a bowel obstruction and is ambulating in the hallway demonstrating a steady gait. B. A client admitted with renal colic who had just received morphine 4 mg IV as prescribed. C. A client admitted with an infected wound on their right foot, a white blood cell count of 14,000/mm³, and a temperature of 37.7°C. D. A client admitted with a tibia fracture scheduled to begin physical therapy with their first crutch walking session.

Correct Answer is B

Explanation

Choice A reason: This client, although admitted with a bowel obstruction, is currently demonstrating a steady gait while ambulating, suggesting that they are stable at the moment.

Choice B reason: This client is the priority because they have just received morphine, which requires close monitoring for potential adverse effects, such as respiratory depression. Morphine is a potent opioid, and its administration necessitates vigilant observation to ensure the client's safety.

Choice C reason: While the client with an infected wound and an elevated white blood cell count and temperature requires attention for infection management, the immediate risk of adverse effects from morphine administration takes precedence.

Choice D reason: This client, scheduled to begin physical therapy, is stable enough to participate in planned rehabilitation activities, making them a lower priority compared to the client who has just received a potent opioid.

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A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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