A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?
"You can delegate this task if the AP has been trained to use our scales."
"You should not delegate this task because you have the capability to obtain clients' weights.”
"You should not delegate this task because it requires nursing judgment."
"You can delegate this task to an AP for new clients before performing a nursing assessment.”
The Correct Answer is A
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “Rise slowly when getting out of bed.": Furosemide is a loop diuretic that can cause orthostatic hypotension due to fluid loss. Teaching the client to rise slowly helps prevent dizziness and falls associated with sudden position changes.
B. "Eat foods that are high in sodium.": Sodium intake should be limited in clients with heart failure, as high sodium can worsen fluid retention and counteract the effects of diuretics like furosemide.
C. “Taking furosemide can cause you to be overhydrated.": Furosemide increases urine output and poses a risk of dehydration, not overhydration. Monitoring fluid balance is essential during treatment.
D. "Taking furosemide can cause your potassium levels to be high.": Furosemide can lead to hypokalemia (low potassium), not hyperkalemia. Clients may need potassium supplementation or dietary adjustments to prevent electrolyte imbalance.
Correct Answer is C
Explanation
A. Avoid eating seafood to minimize risk to the newborn: Seafood contains important nutrients like omega-3 fatty acids that support infant brain development; moderate consumption of low-mercury seafood is generally safe and encouraged during breastfeeding.
B. Wait 1 hour to breastfeed after consuming alcohol: Alcohol peaks in breast milk approximately 30 to 60 minutes after consumption; waiting only 1 hour may not be sufficient to prevent infant exposure depending on the amount consumed.
C. Consume additional calories each day to support milk production: Breastfeeding increases a mother’s energy needs by about 450 to 500 calories per day, so additional caloric intake is necessary to maintain adequate milk supply and support maternal health.
D. Caffeine slowly enters breast milk after maternal consumption: Caffeine passes into breast milk relatively quickly, usually within 30 to 60 minutes after ingestion, so it does not enter slowly but rather fairly rapidly after consumption.
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