A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?

Changing a sterile dressing on a client's open wound

Performing postmortem care for a client

Interpreting a client's laboratory values

Inserting a client's NG tube

Answer and Explanation

The Correct Answer is B

Rationale:

A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.

B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.

C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.

D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

A. A client who has narcissistic personality disorder and refuses to be alone in their room B. A client who has social anxiety disorder and refuses to attend group therapy C. A client who has bipolar disorder and exhibits impulsive behavior D. A client who has panic disorder and exhibits paresthesia

Correct Answer is C

Explanation

Rationale:

A. A client who has narcissistic personality disorder and refuses to be alone in their room: Clients with narcissistic personality disorder typically display a need for admiration and may fear abandonment, but they are not at increased risk for physical injury.

B. A client who has social anxiety disorder and refuses to attend group therapy: Avoidance of social settings is a hallmark of social anxiety disorder. While it may lead to isolation, it does not place the client at increased risk for physical injury.

C. A client who has bipolar disorder and exhibits impulsive behaviour: Impulsivity during manic episodes in bipolar disorder can lead to high-risk activities such as reckless driving, substance use, or unsafe sexual behavior. These behaviors significantly elevate the client’s risk for accidental or intentional physical injury.

D. A client who has panic disorder and exhibits paresthesia: Paresthesia, such as tingling or numbness, is a common symptom during panic attacks but does not directly increase the risk for physical injury. While distressing, it typically resolves and is not associated with unsafe behaviors.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting in the care of a group of clients. Which of the following clients should the nurse identify as being at an increased risk for physical injury?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about advance directives with a client. Which of the following client statements indicates an understanding of the teaching?

A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who has experienced a divorce. Which of the following priority actions should the nurse take to promote secondary prevention?

A nurse is assisting with the care of a client and asks the client. "Can you tell me about your day so far?" Which of the following therapeutic techniques is the nurse using?

A nurse is discussing issues regarding controlled substances and reporting with a newly licensed nurse in an inpatient facility. Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching?

A nurse delegates a task to an assistive personnel (AP) who refuses to complete the task. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client in the emergency department. Exhibits Which of the following interventions should the nurse take? Select the 4 interventions the nurse should take.

A nurse is assisting in the care of a client in an outpatient substance use disorder clinic who has been taking naltrexone for the past 30 days. Which of the following client statements indicates an expected response to the treatment?