A nurse on a medical-surgical unit is observing an assistive personnel (AP) provide care for a group of clients. Which of the following actions by the rag AP requires intervention by the nurse?

Ambulates a client who is 2 days postoperative following a total hip arthroplasty

Performs a simple dressing change on a client's foot wound

Measures the urinary output of a client who has an indwelling urinary catheter

Evaluates the effectiveness of the client's pain medication

Answer and Explanation

The Correct Answer is D

Rationale:
A. Ambulating a postoperative client is within the scope of practice for an AP, as long as the client is stable and the nurse has assessed them first. The AP can assist with mobility under the nurse’s supervision.

B. Performing a simple dressing change may be within the AP’s scope if it is a basic, non-sterile dressing. APs are allowed to perform routine hygiene or dressing tasks that do not require assessment or sterile technique.

C. Measuring urinary output is a routine task that APs can perform. The nurse is responsible for interpreting the measurements, but obtaining and recording output is appropriate delegation.

D. Evaluating the effectiveness of pain medication requires assessment, judgment, and clinical decision-making, which are nursing responsibilities. APs do not have the training or authority to determine if a client’s pain management is adequate or to make decisions about medication administration. This action requires immediate intervention by the nurse.

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Correct Answer is A

Explanation

Rationale:
A. An occupational therapist (OT) specializes in helping clients perform activities of daily living (ADLs) such as dressing, bathing, eating, and household tasks. The OT can assess the client’s functional abilities, recommend adaptive equipment, and provide strategies to safely complete tasks at home. This makes the OT the most appropriate team member for concerns about ADLs.

B. A social worker assists with psychosocial support, financial concerns, community resources, and discharge planning, but does not provide direct interventions to improve the client’s ability to perform ADLs.

C. A risk manager focuses on safety and compliance issues within the facility, not individual client functional independence at home.

D. A physical therapist (PT) works to improve mobility, strength, balance, and endurance. While PT can indirectly support ADLs through improving mobility, the OT focuses specifically on task performance and adaptation in the client’s environment, making them the priority for ADL concerns.

A. Toxoplasmosis B. Candida C. Systemic lupus erythematosus D. Lyme disease

Correct Answer is D

Explanation

Rationale:
A. Toxoplasmosis is typically not a nationally notifiable disease in most states unless it is part of a specific outbreak or associated with congenital infections. Routine cases are generally managed by the healthcare provider and reported at the local level if required.

B. Candida infections are usually common and opportunistic, not reportable to the CDC unless part of an outbreak investigation.

C. Systemic lupus erythematosus (SLE) is an autoimmune condition and not considered a reportable disease. Reporting is not required for routine surveillance.

D. Lyme disease is a nationally notifiable disease. The CDC requires reporting of confirmed and probable cases to monitor epidemiological trends, identify outbreaks, and implement public health interventions. Reporting helps track geographic distribution and incidence of tick-borne illnesses.

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A nurse on a medical-surgical unit is observing an assistive personnel (AP) provide care for a group of clients. Which of the following actions by the rag AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to discharge a client to their home. The client tells the nurse that they are concerned about performing ADLs at home. Which of the following members of the interprofessional team should the nurse consult?

Correct Answer is A

Explanation

A nurse working in the health department is reviewing the charts of four clients. Which of the following client conditions should the nurse identify as reportable to the CDC?

Correct Answer is D

Explanation

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