A nurse is delegating care for a client.

Exhibit 1

Nurses' Notes 1000:

Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.

Assist the client with completing their food menu.

Document the client's urine output

Monitor the client for manifestations of aspiration pneumonia

initiate a referral with the speech language pathologist E. Instruct the client on swallowing techniques

Ambulate the client.

Obtain the client's vital signs.

Answer and Explanation

Correct Answer : B,F,G

Role of assistive personnel is activities of daily living, document input and output, obtain stable vitals as well assist clients in ambulating.

A. The choice of food should consider the risk of aspiration and should include soft food. The high-risk client needs the involvement of a nurse

C. Monitoring the client for features of aspiration pneumonia is in the scope of a registered nurse as it requires clinical judgment and knowledge. –

D. Initiating referral to a speech language pathologist is in the scope of a nurse.

E. Instructing on swallowing techniques is an intervention performed by nurses as it requires demonstration of safety techniques.

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Correct Answer is C

Explanation

In this scenario, the nurse has a role to respect the parents’ autonomy but also be an advocate for the health of the client who is a minor. The nurse needs the input of the ethics committee to assist in navigating the ethical dilemma.

The other clients’, A, B and D, do not pose any ethical dilemmas for the nurse as they are adult and can make legally binding decisions.

A. The client B. The partner C. The provider D. The oldest adult child

Correct Answer is A

Explanation

The oldest child has durable power of attorney to make healthcare decision on behalf of the client when he is unable to make decisions. However, the client in this case is fully oriented and, therefore, he is legally allowed to make the decision unless he explicitly gives the authority to the partner, provider or oldest child.

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A nurse is delegating care for a client. Exhibit 1 Nurses' Notes 1000: Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?

A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?

A nurse is delegating care for a client.

Exhibit 1

Nurses' Notes 1000:

Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.