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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.

Collect a stool sample for ova and parasites from a school-age child

Engage a toddler in play.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.

D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.

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Correct Answer is B

Explanation

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

A. Client 3 Collect and label specimen. B. Client 1: Perform prescribed procedure. C. Client 3 Administer prescribed medication. D. Client 4 Perform prescribed testing E. Client 4 Provide prescribed wound care F. Client 2: Transport client for diagnostic testing.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Client 3: Collect and label specimen.

Assistive personnel- Assistive personnel can handle the collection and labeling of specimens, which is a routine task that does not require advanced clinical judgment.

Client 1: Perform prescribed procedure.

Practical Nurse- Insertion of a nasogastric tube is a procedure that requires clinical skills and knowledge, making it appropriate for a licensed practical nurse (LPN) to perform.

Client 3: Administer prescribed medication.

Practical Nurse- Administering medication is within the scope of practice for a practical nurse, as they are trained to handle medications and monitor their effects.

Client 4: Perform prescribed testing.

Assistive personnel- Testing such as using a glucometer for blood glucose monitoring can be performed by assistive personnel under the supervision of a registered nurse or practical nurse.

Client 4: Provide prescribed wound care.

Practical Nurse- Wound care, especially for a non-healing wound and cellulitis, requires clinical assessment and skills that a practical nurse is trained to provide.

Client 2: Transport client for diagnostic testing.

Assistive personnel- Transporting clients to diagnostic testing is a task that can be safely performed by assistive personnel.

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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

Correct Answer is B

Explanation

The charge nurse is planning to delegate client care tasks. Exhibits For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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