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

Reinforcing teaching with a client about stool specimen collection

Collecting a urine specimen from a client who is experiencing dysuria

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

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

Answer and Explanation

The Correct Answer is B

A) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

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

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

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

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.

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Correct Answer is D

Explanation

A) Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.

B) Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.

C) Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.

D) Activate the alarm outside the client's room: This is the most appropriate action to take first. Activating the alarm alerts others to the fire, enabling them to respond promptly and effectively. It initiates the facility's fire response protocol, including evacuating occupants and summoning the fire department. This action ensures the safety of everyone in the vicinity and allows for a coordinated emergency response.

A. A newborn has an Apgar score of 7 at 5 min after birth. B. A newborn has respiratory distress and requires oxygen. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

Correct Answer is D

Explanation

A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Correct Answer is C

Explanation

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