A nurse manager is making morning assignments for the nursing team. Which duties can be assigned to the nursing assistant/unlicensed worker? Select all that apply.

Changing the linen of a client on a pressure-releasing mattress

Repositioning a client on complete bed rest

Teaching a client on an anticoagulant about using an electric razor

Transferring a client from the bed to the chair using a mechanical lift

Totaling the oral intake and output for the entire unit.

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:

A. Primary care involves ongoing management of chronic diseases, preventive screenings, routine health maintenance, and long-term patient relationships. Emergency department (ED) nursing differs because patients present with acute illnesses, injuries, or exacerbations, often requiring immediate stabilization. The ED is not a setting for preventive or longitudinal care, so focusing on primary care does not reflect the role of the ED nurse.

B. ED nurses provide rapid assessment, monitoring, and intervention for patients with life-threatening or emergent conditions such as trauma, myocardial infarction, stroke, sepsis, or respiratory distress. This requires advanced clinical skills, critical thinking, and the ability to prioritize interventions quickly. Unlike med-surg or outpatient units, where patients often have known diagnoses and stable conditions, the ED often deals with unstable patients whose status can deteriorate rapidly.

C. ED nurses care for neonates, children, adults, and older adults—sometimes all in the same shift. This requires knowledge of age-specific assessments, vital signs, medication dosages, and communication techniques. In contrast, many nursing units specialize in a specific age group, such as pediatrics or geriatrics.

D. Patients usually present with symptoms rather than confirmed diagnoses, such as chest pain, shortness of breath, abdominal pain, or altered mental status. ED nurses must perform rapid and accurate assessments, interpret diagnostic tests, anticipate complications, and implement interventions without having the full picture. This level of uncertainty distinguishes ED nursing from units where the diagnosis is already established.

E. Care in the ED is typically short-term and focused on stabilization. Once patients are stabilized, they are discharged, admitted, or transferred to another unit. ED nurses do not usually provide long-term follow-up or chronic disease management. This episodic nature contrasts with inpatient med-surg or primary care, where nurses often develop longitudinal care plans and maintain continuity of care.

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

Explanation

Rationale:

A. Hepatitis A is highly contagious via the fecal-oral route. There is no specific medication to prevent transmission once infected. Family members need to practice strict hygiene, including handwashing and avoiding shared utensils, to prevent spread.

B. Towels and personal items can harbor the virus, and not sharing them reduces the risk of transmission. No further teaching is needed for this statement.

C. This indicates misunderstanding. Hepatitis A is not transmitted via airborne droplets, so masks are unnecessary. Transmission occurs primarily through fecal-oral contamination, not respiratory secretions.

D. Alcohol is hepatotoxic and should be completely avoided during hepatitis A infection and recovery to prevent additional liver damage. This statement indicates a need for further teaching.

E. Sexual activity, especially oral-anal contact, can spread hepatitis A. Close contact and kissing may also pose a risk if hand hygiene is inadequate. The client needs further teaching about precautions to prevent transmission to intimate partners.

A. Immediately reassess the client and assign the category of urgent. B. Remind the individual to be client and wait to be seen. C. Immediately reassess the client and begin resuscitation. D. Immediately reassess the client and assign the category of emergent.

Correct Answer is D

Explanation

Rationale:

A. “Urgent” indicates the client needs timely evaluation but is not at immediate risk of life or limb. Shortness of breath and dizziness suggest a potentially life-threatening deterioration, requiring a higher priority than urgent.

B. This is unsafe. The client is showing new signs of acute distress, and waiting could result in further deterioration or death. Immediate reassessment and escalation are required.

C. While resuscitation may be needed if the client is hemodynamically unstable, the first step is to reassess and triage appropriately. Resuscitation is initiated based on findings from reassessment, not automatically for all clients with shortness of breath and dizziness.

D. The client’s new symptoms of shortness of breath and dizziness indicate potential life-threatening complications. In the triage system, the category of emergent is reserved for clients whose conditions could rapidly worsen or threaten life or limb. Immediate reassessment allows the nurse to identify vital sign changes, begin interventions if needed, and escalate care appropriately, ensuring the client is seen promptly.

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A nurse manager is making morning assignments for the nursing team. Which duties can be assigned to the nursing assistant/unlicensed worker? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply.

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

Explanation

A client assigned the category of nonurgent in the emergency department, begins to have shortness of breath and is dizzy. What should be done to assist this client?

Correct Answer is D

Explanation

The nurse prepares to administer 18 units/kg/hr of heparin to client weighing 80 kg. The heparin is supplied in a concentration of 25,000 units in 250 mL of normal saline. How many mL/hr would the nurse deliver the heparin? Round to a whole number.

The nurse assesses a client with severe pruritus as a complication of cirrhosis. Which intervention should the nurse delegate to the unlicensed assistive personnel?

The nurse assesses a client admitted with advanced cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.

The nurse prepares to administer 500 mL of normal saline to infuse at 175 mL/hr for a client who is vomiting. The IV tubing has a drop factor of 15 gtt/mL. How many gtt/min will the client receive? Round to a whole number.

A nurse is caring for a client in the emergency department (ED). Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is exhibiting manifestations of dropdown due to the client's ­­ dropdown

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

The nurse assesses a client with a chest tube inserted to treat pneumothorax. Which assessment finding best indicates that a chest tube is no longer needed?

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