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 A

Explanation

A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

A. Alcohol-based antiseptic rub B. Nonantimicrobial soap C. Triclosan D. Chlorhexidine gluconate

Correct Answer is B

Explanation

A. Alcohol-based antiseptic rub: Alcohol-based hand rubs are ineffective against C. difficile spores.
B. Nonantimicrobial soap: Handwashing with soap and water is essential to physically remove C. difficile spores from the skin.
C. Triclosan: Triclosan is an antimicrobial agent used in some handwashes but lacks efficacy against C. difficile spores.
D. Chlorhexidine gluconate: While effective against a broad spectrum of bacteria, it does not reliably kill C. difficile spores.

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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

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