A nurse is planning to delegate care for a male client who has anemia
Measure the client's urine output.
Reinforce teaching with the client about the transfusion.
Insert a peripheral IV.
Check the client's vital signs every 15 min.
Obtain daily weights on the client.
Correct Answer : A,E
Rationale:
A. Measuring urine output is a routine, stable task that can be safely delegated to an assistive personnel (AP).
B. Reinforcing teaching about the transfusion requires nursing knowledge and judgment and cannot be delegated.
C. Inserting a peripheral IV is an invasive procedure requiring nursing skill and licensure, so it cannot be delegated.
D. Checking vital signs every 15 minutes during a blood transfusion requires assessment for transfusion reactions and immediate nursing intervention, so it must be performed by a nurse.
E. Obtaining daily weights is a routine measurement that an AP can safely perform.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Asking the son to leave allows the nurse to interview and assess the client privately. This ensures the client can speak freely about possible abuse without fear of intimidation.
B. Asking about injuries in the presence of the possible abuser may prevent the client from disclosing abuse and could place the client at further risk.
C. An incident report is for internal facility events (e.g., falls, medication errors), not for suspected abuse. Abuse must be reported to the appropriate authorities, not just documented internally.
D. Discharging the client without investigation puts the client at continued risk of harm and fails to meet the nurse’s legal obligation to protect vulnerable populations.
Correct Answer is B
Explanation
Rationale:
A. Discussing the risks of the procedure is the provider’s responsibility, not the nurse’s. The provider must ensure informed consent.
B. If the client expresses concerns after signing consent, the nurse should notify the provider immediately so the provider can clarify information, answer questions, and reconfirm consent.
C. The nurse does not have the authority to postpone the procedure; that decision must be made by the provider.
D. Emphasizing the importance of the procedure could be seen as coercive and does not respect the client’s right to informed decision-making.
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