A nurse is making shift assignments.
Which client is appropriate for a nursing assistant?
A newly admitted client with a seizure disorder.
A post-op laparotomy client who is waiting for discharge instructions.
A client who needs assistance with feeding.
A dehydrated client with an electrolyte imbalance.
The Correct Answer is C
Choice A rationale
A newly admitted client with a seizure disorder requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Choice B rationale
A post-op laparotomy client who is waiting for discharge instructions requires specific education and assessment, which is beyond the scope of practice for a nursing assistant.
Choice C rationale
A client who needs assistance with feeding is the correct answer. Assisting with feeding is within the scope of practice for a nursing assistant.
Choice D rationale
A dehydrated client with an electrolyte imbalance requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The assessment component of the SBAR report includes the nurse’s evaluation of the patient’s condition, such as pain level, blood pressure, and heart rate. This information is critical for the provider to understand the patient’s current status and make informed decisions.
Choice B rationale
The situation component of the SBAR report provides a brief overview of the patient’s current situation, such as the reason for the call or the immediate concern. It does not include detailed assessment data.
Choice C rationale
The recommendation component of the SBAR report includes the nurse’s suggestions for the next steps or actions to be taken. It does not include the patient’s assessment data.
Choice D rationale
The background component of the SBAR report provides relevant medical history and context for the patient’s current condition. It does not include the detailed assessment data.
Correct Answer is D
Explanation
Choice A rationale
Correcting the physician’s orders to match the chart is not within the nurse’s scope of practice. Nurses should not alter physician orders.
Choice B rationale
Ignoring the discrepancy is not appropriate. Nurses have a responsibility to ensure patient safety and accurate documentation.
Choice C rationale
Documenting the discrepancy but taking no further action does not address the potential risk to patient safety. Further action is necessary.
Choice D rationale
Documenting the discrepancy and notifying the physician is the correct course of action. This ensures that the physician is aware of the issue and can make any necessary corrections.
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