A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Abdominal pain: Abdominal pain is not typically associated with respiratory acidosis. Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide, resulting in an acidic blood pH.

B. Lethargy: Lethargy is a common symptom of respiratory acidosis. Patients may experience fatigue, especially during the daytime1. This is due to the increased carbon dioxide levels in the blood, which can cause confusion, drowsiness, and fatigue

C. Dry skin: Dry skin is not a common symptom of respiratory acidosis. The condition primarily affects the respiratory system and does not typically cause skin changes.

D. Numbness of fingers: While numbness of fingers can be a symptom of various conditions, it is not typically associated with respiratory acidosis. The primary symptoms of respiratory acidosis are related to increased carbon dioxide levels in the blood, such as lethargy and confusion.

A. Vomiting B. Hyperventilation C. Darthea D. Salicylate intoxication

Correct Answer is D

Explanation

A. Vomiting:

Vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, resulting in increased bicarbonate levels in the blood. It does not directly contribute to metabolic acidosis.

B. Hyperventilation:

Hyperventilation can lead to respiratory alkalosis due to excessive elimination of carbon dioxide (CO2) through increased respiratory rate and depth. It is not associated with metabolic acidosis.

C. Diarrhea:

Diarrhea can lead to metabolic acidosis due to the loss of bicarbonate-rich fluid from the gastrointestinal tract, resulting in decreased bicarbonate levels in the blood. While diarrhea can contribute to metabolic acidosis, it is not the case in this scenario.

D. Salicylate intoxication:

Salicylate intoxication, such as aspirin overdose, can lead to metabolic acidosis due to the accumulation of salicylic acid, which is a weak acid that dissociates in the body, contributing to an increased anion gap metabolic acidosis. This is a direct cause of metabolic acidosis in this scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?

Correct Answer is D

Explanation

A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid- base imbalances should the nurse suspect?

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid- base imbalances should the nurse suspect?

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are: PH: 7.6 PaCO2: 40 mm Hg HCO3,: 32 mEq/L Which of the following acid base conditions should the nurse identify the client is experiencing?

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia?

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?