A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Accompany a client who has depression to occupational therapy.

Initiate soft wrist restraints on a client who is at risk for self-harm.

Sit with a client who has alcohol use disorder and whose last drink was five days ago.

Set limits with a client who has mania.

Work a jigsaw puzzle with a client who has dementia.

Assess a client who has hypomania for exhaustion.

Answer and Explanation

Correct Answer : A,E

A.   This is a routine task that can be safely delegated to a NAP. It does not require complex decision- making or assessment skills.
B.   This task requires the ability to assess the client's condition and determine the appropriate level of restraint. It is a task that should be performed by an RN or licensed practical nurse (LPN).
C.   While this may seem like a simple task, it requires the ability to monitor the client for signs of withdrawal and to intervene if necessary. It is a task that should be performed by an RN or LPN.
D.   This task requires the ability to assess the client's behavior and to intervene if necessary. It is a task that should be performed by an RN or LPN.
E.   This is a therapeutic activity that can be delegated to a NAP. It can help to stimulate the client's cognitive function and provide social interaction.
F.   This task requires the ability to assess the client's condition and identify potential complications. It is a task that should be performed by an RN or LPN.

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Correct Answer is C

Explanation

A. While nurses can verify that a consent form is signed, they do not typically have the authority to ensure it is completed correctly or to explain the details of the procedure, which is the responsibility of the surgeon. The nurse's role is to ensure the client understands the procedure and has had the opportunity to ask questions, but they do not explain the surgery itself in detail.
B. This is a key responsibility of the nurse. Assessing the client's health status before surgery is critical for identifying any potential risks or issues that may affect the surgical outcome. This includes physical assessments and reviewing the client’s medical history.
C. This action is considered outside the nurse's responsibilities. The explanation of the operative procedure, risks, and benefits is typically the responsibility of the surgeon or the physician performing the surgery. Nurses may provide general information or support but are not the ones who explain the specifics of the surgical procedure.
D. Nurses are responsible for reviewing and interpreting preoperative laboratory results to ensure the client is medically ready for surgery. This review helps identify any abnormalities that may need to be addressed before proceeding with the surgical procedure.

A. "You have a low ferritin level." B. ‘You have an autoimmune disease." C. “You have fewer red blood cells." D. “You have had a gastrointestinal bleed."

Correct Answer is C

Explanation

A. While low ferritin levels can indicate iron deficiency anemia, sickle cell anemia primarily involves the production of abnormal hemoglobin rather than iron deficiency. Fatigue in sickle cell anemia is more closely related to the effects of the disease itself, including chronic hemolysis and decreased red blood cell survival.
B. Sickle cell anemia is not classified as an autoimmune disease; it is a genetic disorder caused by a mutation in the hemoglobin gene. While individuals with sickle cell anemia may have increased susceptibility to infections, the fatigue they experience is not due to an autoimmune process.
C. Sickle cell anemia leads to chronic hemolytic anemia, meaning the abnormal sickle-shaped red blood cells break down more quickly than normal red blood cells. This results in a lower overall red blood cell count (anemia), which can cause fatigue and weakness due to reduced oxygen-carrying capacity in the blood.
D. While gastrointestinal bleeding can lead to fatigue due to blood loss and subsequent anemia, it is not a direct consequence of sickle cell anemia. If the client had experienced a gastrointestinal bleed, it would typically need to be evaluated independently of their sickle cell disease.

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A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Correct Answer is C

Explanation

A nurse is caring for a client who has sickle cell anemia. The client asks. "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

Correct Answer is C

Explanation

A nurse at a community clinic is reinforcing education for a newly licensed nurse about nursing advocacy. Which of the following actions should the nurse include as an example of nursing advocacy?

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A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

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When monitoring medication inventories for possible diversion or theft by nurses who abuse chemicals, what medication classifications should be monitored most closely? [SELECT ALL THAT APPLY]

Which term best describes sickle cell disease?

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching?(Select All that Apply.)

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