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.
Obtain the client's vital signs.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Being difficult to arouse may be and indicator of respiratory depression which is a common side effect of opioid use. This is more common when given in high doses. Although benzodiazepines could cause respiratory depression, the risk is lower.
A. opioid is more likely to be the cause of respiratory depression
C. continuing the medications despite the increased risk of respiratory depression is unethical
D. An NSAID is unlikely to provide optimal analgesia which is a key goal in end of life care,
Correct Answer is A
Explanation
Websites with a gov address are reliable sources of information as they are regularly vetted as an accurate source of information
C. Although podcasts can be used, the information is not reliable as some of it is based on opinions which are not evidence based.
B. a licensed practical nurse may not have sufficient knowledge to address the client’s needs.
D. Articles on specific treatments may be confusing to the client as they may not address their individual concerns.
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