A nurse is delegating care to an assistive personnel. Which of the following assignments should the nurse make?

Taking the vital signs of a client who is experiencing acute angina

Collecting a urine specimen from a client who is experiencing dysuria

Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Reinforcing teaching with a client about stool specimen collection

Answer and Explanation

The Correct Answer is B

A.   Taking the vital signs of a client who is experiencing acute angina. Acute angina is a potentially unstable condition requiring assessment by a nurse.
B.   Collecting a urine specimen from a client who is experiencing dysuria. APs can perform routine specimen collection tasks.
C.   Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure. Only licensed nurses should provide pre-procedure instructions.
D.   Reinforcing teaching with a client about stool specimen collection. Reinforcement of teaching involves assessment and evaluation, which are the nurse’s responsibilities.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Client 1 (First Priority):

Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Bowel pattern B. Oxygen saturation C. Respiratory assessment. D. Temperature E. Neurological status F. X-ray results G. Heart rate

Correct Answer is ["B","C","D","E","F"]

Explanation

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

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A nurse is delegating care to an assistive personnel. Which of the following assignments should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse on a mental health unit is receiving a change of shift report for a group of clients. Exhibits Complete the following sentence by using the lists of options. The nurse should first collect data from dropdowndue to dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is contributing to the plan of care for a client who speaks a different language than the nurse. Which of the following interventions should the nurse include to facilitate communication with the client?

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