A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Evaluate dietary intake for a client who has anorexia.

Measure the vital signs of a client who just returned from the PACU

Arrange the lunch tray for a client who has a hip fracture.

Assess I&O for a client who is receiving dialysis.

Answer and Explanation

The Correct Answer is C

A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.

B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.

C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.

D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.

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Correct Answer is B

Explanation

Choice A reason:

Mild pain in the hip region can be caused by various musculoskeletal issues, such as muscle strains, bursitis, or even referred pain from other areas. It is not a characteristic symptom of scoliosis.

Choice B reason

Scoliosis is characterized by an abnormal sideways curvature of the spine, which can cause uneven shoulders and pelvic heights. As the spine curves abnormally, it can lead to asymmetry in the shoulders and hips, which are noticeable during physical examination. This asymmetry is a key clinical sign that suggests the presence of scoliosis.

Choice C reason:

Limited range of motion (ROM) of the hips is more likely related to hip joint issues or musculoskeletal conditions affecting the hips, not specifically scoliosis.

Choice D reason:

Exaggerated curvature of the sacrum may indicate other spinal abnormalities or conditions affecting the lower back, but it is not typically associated with scoliosis, which primarily affects the curvature of the spine higher up in the thoracic or lumbar regions.

A. Low-sodium diet B. Potassium 40 mEq PO daily C. Initiate suicide precautions D. Fluoxetine 20 mg PO daily

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A. Low-sodium diet Contraindicated: A low-sodium diet can decrease lithium elimination, leading to increased lithium levels and risk of toxicity in lithium users. B. Potassium 40 mEq PO daily Anticipated: Potassium supplementation may be needed to prevent hypokalemia, which can occur due to lithium-induced polyuria or diuretic use. C. Initiate suicide precautions Anticipated: Suicide precautions are essential for any client who has attempted or expressed suicidal ideation, especially during the depressive phase of bipolar disorder. D. Fluoxetine 20 mg PO daily Contraindicated: Fluoxetine is an SSRI antidepressant, which can cause angioedema in clients who are allergic to SSRIs. Additionally, fluoxetine can trigger manic episodes or increase suicidal risk in clients with bipolar disorder.

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A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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