A nurse on a medical-surgical unit has just received a change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel?

Showing a client who has a new colostomy how to empty the pouch.

Reinserting an NG tube for a client who requires gastric decompression

Performing a closed catheter irrigation for a client who is postoperative

Bathing a client who has hemiparesis following a stroke

Answer and Explanation

The Correct Answer is D

A.   Showing a client who has a new colostomy how to empty the pouch. Client education requires the clinical knowledge and teaching skills of a nurse.
B.   Re-inserting an NG tube for a client who requires gastric decompression. NG tube insertion is a skilled task that requires clinical assessment and monitoring by a nurse.
C.   Performing a closed catheter irrigation for a client who is postoperative. Closed catheter irrigation requires sterile technique and clinical judgment, which are nursing responsibilities.
D.   Bathing a client who has hemiparesis following a stroke. APs can assist with bathing and hygiene tasks.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Client 1 (First Priority):

Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Observe the client's verbal and nonverbal behaviors. B. Ask the client's adolescent child to act as an interpreter. C. Avoid the use of gestures. D. Speak directly to the interpreter.

Correct Answer is A

Explanation

A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

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A nurse on a medical-surgical unit has just received a change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse on a mental health unit is receiving a change of shift report for a group of clients. Exhibits Complete the following sentence by using the lists of options. The nurse should first collect data from dropdowndue to dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

A nurse is contributing to the plan of care for a client who speaks a different language than the nurse. Which of the following interventions should the nurse include to facilitate communication with the client?

Correct Answer is A

Explanation

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