A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV Infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

Report any IV infusion alarms.

Regulate the IV flow rate.

Change the IV solution bag.

Calculate IV intake.

Answer and Explanation

The Correct Answer is A

Safe delegation of nursing tasks involving intravenous therapy requires distinguishing between actions that require clinical judgment and those that are observational in nature. A client receiving 0.45% sodium chloride via continuous infusion requires careful monitoring for complications such as infiltration, occlusion, or pump malfunction. Assistive personnel (AP) may assist with basic observations and reporting but cannot perform tasks that require assessment, clinical decision-making, or manipulation of sterile equipment. The nurse remains responsible for managing and adjusting IV therapy.

Rationale:
A. Reporting IV infusion alarms is an appropriate task for assistive personnel because it involves observation and communication rather than clinical decision-making. In a client receiving 0.45% sodium chloride, pump alarms may indicate occlusion, infiltration, or empty fluid containers. The AP should promptly notify the nurse so that appropriate assessment and intervention can be performed.

B. Regulating the IV flow rate is not appropriate for assistive personnel because it requires clinical judgment and adjustment based on the client’s condition and prescribed rate. Changes in IV infusion require nursing assessment to ensure safe fluid administration and prevent complications such as fluid overload or under-infusion.

C. Changing the IV solution bag is a sterile procedure that requires nursing knowledge and skill to maintain aseptic technique and ensure correct solution administration. Errors in IV fluid replacement can lead to serious complications such as electrolyte imbalance or infection. This task cannot be delegated to AP.

D. Calculating IV intake requires interpretation of fluid balance and clinical judgment to evaluate hydration status. This is part of nursing assessment and is essential in monitoring renal function, fluid overload, or deficit. Therefore, it is not appropriate for delegation to assistive personnel.

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 C

Explanation

Rib fractures can lead to serious thoracic complications such as pneumothorax, hemothorax, or tension pneumothorax due to underlying lung injury. Nurses must prioritize assessment for signs of respiratory compromise and mediastinal shift, as these conditions can rapidly become life-threatening. Clinical findings that indicate impaired ventilation or altered intrathoracic pressure require immediate escalation of care. Early recognition is essential to prevent respiratory failure and cardiovascular collapse.

Rationale:
A. Hypotension may occur with significant blood loss or tension pneumothorax, but it is a late sign of deterioration. While concerning, it does not specifically indicate the most immediate life-threatening thoracic shift compared to tracheal deviation. It should be addressed urgently but follows airway and structural compromise indicators.

B. Crepitus is a common finding in rib fractures and represents air trapped in subcutaneous tissue. Although it indicates underlying injury such as air leakage from the lung, it is not immediately life-threatening on its own. It requires monitoring but is not the priority compared to signs of mediastinal shift.

C. Tracheal deviation is the priority finding because it indicates a possible tension pneumothorax, a life-threatening condition caused by increasing intrathoracic pressure that shifts mediastinal structures. This can compromise both ventilation and venous return, leading to rapid cardiovascular collapse. In conditions such as Pneumothorax, tracheal deviation is an emergency sign requiring immediate intervention.

D. Pain on inspiration is expected with rib fractures due to movement of the chest wall during breathing. While it requires pain management to promote adequate ventilation, it is not an indicator of life-threatening complications. It is considered an anticipated symptom rather than an urgent finding.

A. Discourage the client from reminiscing. B. Encourage the client to eat meals in their room. C. Limit directions for the client to three at a time. D. Provide finger foods for the client at mealtimes.

Correct Answer is D

Explanation

Care planning for a client with dementia focuses on maintaining safety, promoting independence, and supporting adequate nutrition while minimizing confusion and frustration. Clients with dementia often experience cognitive decline that affects memory, judgment, and executive functioning, making structured communication and simplified tasks essential. Interventions should enhance the client’s ability to participate in self-care while reducing environmental and cognitive demands. Nutrition is particularly important because these clients are at risk for poor intake due to forgetfulness or difficulty with utensils.

Rationale:
A. Discouraging reminiscence is not appropriate because recalling past experiences can provide comfort and promote engagement in clients with dementia. Reminiscence therapy is often used to stimulate memory and support emotional well-being. Preventing this activity may increase confusion and reduce therapeutic interaction.

B. Encouraging the client to eat meals in their room may increase isolation and reduce social stimulation, which can worsen cognitive decline and appetite. Mealtime in a structured communal setting often promotes better intake and orientation through routine. Social interaction can also enhance engagement and reduce agitation.

C. Limiting directions to three at a time is a useful communication strategy, but it does not directly address nutrition or mealtime safety needs in this question. While simplifying instructions is important, it is not the most appropriate intervention related specifically to improving eating ability and independence.

D. Providing finger foods supports independence and improves nutritional intake by allowing the client to eat without needing complex utensil use. In Dementia, clients often have difficulty with coordination and sequencing tasks, so finger foods make eating easier, safer, and more successful. This intervention directly enhances function and reduces the risk of malnutrition.

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 is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV Infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has fractured ribs. Which of the following is the priority finding the nurse should report to the provider?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following Instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis. Which of the following information should the nurse include in the teaching?

A nurse is performing blood glucose monitoring on a client. Which of the following actions should the nurse take?

A nurse is caring for a client who is experiencing warfarin toxicity. Which of the following medications should the nurse administer?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?