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 B

Explanation

Instrucing them to discontinue the conversation immediately offers a solution instantly protecting the client's confidentiality.

While notifyin the provider and completing an incident report may be feasile, they may delay intervention leading to more harm.

A. Pipe cleaners B. Oxygen tank C. Obturator D. Cotton balls E. Petroleum jelly

Correct Answer is ["B","C"]

Explanation

A. Pipe cleaners are not typically used for tracheostomy care. However, tracheostomy care kits may include brushes or other cleaning devices designed for cleaning the inner cannula of the tracheostomy tube.

B. A portable oxygen tank may be necessary for a client with a tracheostomy, particularly if the tracheostomy was placed due to respiratory insufficiency or if the client needs supplemental oxygen to maintain appropriate oxygen saturation.

C. An obturator is used to insert the tube in the case of dislodgement at home.

D. Cotton balls are generally not recommended for tracheostomy care. They can leave fibers behind and may pose a risk of aspiration. They do not serve a significant purpose in the management of a tracheostomy.

B. An oxygen tan is unsafe for use at home as it increases the risk of fire.

E- Petroleum jelly is useful in the later stages when hyper granulation occurs.

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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 overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?

A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?

A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?

A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?

A nurse is providing teaching to a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

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.