A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Reinserting an NG tube that was pulled out by a client

Recording output for a client who has multiple drains and tubes

Teaching a family member how to change a simple dressing at home

Suctioning a client's tracheostomy that has been in place for 3 days

Answer and Explanation

The Correct Answer is B

Recording output for a client who has multiple drains and tubes is a task that can be delegated to an AP, as it does not require nursing judgment or assessment skills. Reinserting an NG tube, teaching a family member how to change a dressing, and suctioning a tracheostomy are tasks that require nursing judgment, assessment skills, and specialized knowledge, and therefore cannot be delegated to an AP.

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Correct Answer is D

Explanation

Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.

A. Bradycardia B. Flattened neck veins C. Fever D. Crackles in the lungs

Correct Answer is D

Explanation

This is because crackles are a sign of fluid overload in the lungs, which can occur when a client receives too much IV fluid. Fluid overload can cause pulmonary edema, which is a life threatening condition that reduces oxygen exchange in the lungs. Some other signs and symptoms of fluid overload include rapid weight gain, swelling in the arms, legs and face, high blood pressure and shortness of breath.

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A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Correct Answer is D

Explanation

A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Correct Answer is D

Explanation

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?