A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Measure the intake and output of a client who has received furosemide.

Reinforce teaching with a client about crutch-gait walking.

Check a client's peripheral IV site for redness or swelling.

Assess the pain level of a client who has received acetaminophen.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:

A client who has ulcerative colitis is correct. Ulcerative colitis, a type of inflammatory bowel disease (IBD), involves chronic inflammation and ulceration in the colon and rectum. This condition often results in bleeding from the inflamed mucosa, leading to the presence of blood in the stool that can be detected by a fecal occult blood test.

Choice B Reason:

A client who has stomatitis is incorrect. Stomatitis refers to inflammation in the mouth and does not typically cause bleeding in the gastrointestinal tract, which is what the fecal occult blood test detects. Stomatitis involves oral lesions or sores but does not directly impact stool blood content.

Choice C Reason:

A client who uses laxatives is incorrect. Laxative use does not necessarily cause bleeding in the gastrointestinal tract. While some laxatives can potentially irritate the intestinal lining, leading to minor bleeding in some cases, the presence of blood in the stool due to laxative use is less common compared to conditions like ulcerative colitis, where chronic inflammation and ulceration lead to significant bleeding.

Choice D Reason:

A client who has cholecystitis is incorrect. Cholecystitis is inflammation of the gallbladder and does not directly involve bleeding in the gastrointestinal tract. It typically presents with symptoms related to gallbladder inflammation such as abdominal pain, nausea, and vomiting, rather than causing bleeding that would be detected by a fecal occult blood test.

A. Document the refusal in the client's medical record. B. Return the medication to the medication cabinet. C. Inform the client of the potential consequences of their refusal. D. Notify the provider of the client's refusal.

Correct Answer is C

Explanation

Choice A Reason:

While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.

Choice B Reason:

Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.

When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:

Choice C Reason:

Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.

Choice D Reason:

Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.

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 coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?

Correct Answer is A

Explanation

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)