A nurse is reviewing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measuring a client's urinary output

Performing a sterile dressing change on a client

Instructing a client on the use of crutches

Interpreting a client's ECG strip

Answer and Explanation

The Correct Answer is A

Rationale:

A. This option is correct because measuring and recording a client’s urinary output is within the scope of practice for an assistive personnel (AP). This task is noninvasive, routine, and does not require nursing judgment, making it appropriate for delegation.

B. This option is incorrect because performing a sterile dressing change is a nursing intervention that requires knowledge of aseptic technique, assessment skills, and clinical judgment. It cannot be delegated to an AP.

C. This option is incorrect because instructing a client on the use of crutches involves teaching, assessment of the client’s abilities, and evaluation of safety, all of which are nursing responsibilities and cannot be delegated to an AP.

D. This option is incorrect because interpreting an ECG strip requires specialized nursing knowledge and clinical judgment to identify dysrhythmias and respond appropriately. This is outside the AP’s scope of practice.

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Correct Answer is D

Explanation

Rationale:

A. This option is incorrect because advance directives are not permanent and can be changed or revoked at any time, as long as the client is competent to make healthcare decisions. Clients may revise their directives to reflect changes in their health status, personal values, or preferences for medical care. Telling clients they cannot be changed could lead to misunderstandings about their rights and autonomy.

B. This option is incorrect because while consulting an attorney may provide legal guidance, it is not a required step for creating an advance directive. Many advance directives are valid when completed using standardized forms provided by healthcare facilities or state resources without legal review.

C. This option is incorrect because appointing a durable power of attorney (also called a healthcare proxy) is optional. While designating someone to make healthcare decisions on the client’s behalf can be helpful, especially if the client becomes incapacitated, it is not mandatory for an advance directive to be valid.

D. This option is correct because advance directives are intended to document a client’s preferences for end-of-life care. This includes decisions about life-sustaining treatments, resuscitation (CPR), mechanical ventilation, feeding tubes, and other medical interventions. By having an advance directive, clients ensure that their wishes are respected if they become unable to communicate or make healthcare decisions in the future. This empowers clients, guides healthcare providers, and helps prevent unwanted or unnecessary interventions.

A. Tell the nurses to lower their voices when discussing a client. B. Plan an in-service program for the nurses about HIPAA privacy rules, C. Ask the nurses to stop discussing the client's protected health information. D. Inform the nurse manager about the confidentiality breach. E. Complete an incident report about the nurses' breach of confidentiality.

Correct Answer is ["B","C","D","E"]

Explanation

Rationale:

A. This option is incorrect because merely telling the nurses to lower their voices does not address the underlying violation of HIPAA regulations. Protected health information (PHI) should not be discussed in public areas at all, regardless of voice volume.

B. This option is correct because planning an in-service program about HIPAA privacy rules helps educate staff and prevent future breaches of confidentiality. Ongoing staff education reinforces the importance of protecting client information.

C. This option is correct because asking the nurses to stop discussing the client’s PHI immediately addresses the current violation and prevents further unauthorized disclosure. This is an appropriate and immediate intervention to protect client privacy.

D. This option is correct because informing the nurse manager ensures that leadership is aware of the confidentiality breach. The manager can provide guidance, implement corrective action, and ensure compliance with facility policy and legal requirements.

E. This option is correct because completing an incident report documents the breach formally. Incident reports help track violations, facilitate follow-up, and ensure accountability, which is essential for maintaining HIPAA compliance and protecting client privacy.

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A nurse is reviewing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the purpose of advance directives. When assessing the client's understanding of the teaching, which of the following client statements should the nurse expect?

Correct Answer is D

Explanation

A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses discussing the biopsy results of a client who is on the unit. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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