A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?

“I have not received any of my medications today.”

“Do you know when I will be going home?”

“I do not know how to make the remote control work.”

“My dressing was changed earlier this morning.”

Answer and Explanation

The Correct Answer is A

A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.

B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.

C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.

D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.

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Correct Answer is C

Explanation

A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.

B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.

C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.

D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.

A. Suppress respiratory effort B. Decrease chest wall compliance C. Decrease respiratory secretions D. Induce sedation

Correct Answer is A

Explanation

A. Suppress respiratory effort
Pancuronium is a neuromuscular blocking agent that is often used to induce paralysis in patients requiring mechanical ventilation. It works by blocking the transmission of nerve impulses at the neuromuscular junction, leading to skeletal muscle paralysis. In the context of a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation, the use of pancuronium helps to suppress respiratory effort, allowing for better control of the patient's ventilation and oxygenation.

B. Decrease chest wall compliance:
Pancuronium does not directly affect chest wall compliance. It primarily acts on skeletal muscles, leading to paralysis.

C. Decrease respiratory secretions:
Pancuronium is not used to decrease respiratory secretions. It is a neuromuscular blocking agent with the main goal of inducing paralysis.

D. Induce sedation:
Pancuronium does not induce sedation. It works on the neuromuscular junction and does not have sedative properties. Sedation may be achieved with other medications, such as sedative agents.

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A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

Correct Answer is C

Explanation

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Correct Answer is A

Explanation

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