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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Documentation audits for use of clinical guidelines measure process compliance, not direct client outcomes. They help ensure protocols are followed but do not directly reflect improvement in health outcomes.

B. Percentage of completed client plans of care is also a process measure, assessing whether documentation tasks are completed, rather than whether clients’ health outcomes have improved.

C. Surgical site infection rates are a direct client outcome measure. A decrease in infection rates indicates that care interventions and quality improvement initiatives are effectively improving patient health outcomes. This measurement reflects the actual impact of nursing and medical care on patient safety and recovery.

D. Staffing ratio audits assess resource allocation and workload but do not directly measure patient health outcomes. While staffing affects outcomes indirectly, it is a structural measure rather than an outcome measure.

A. Research participant B. Risk manager C. Institutional review board D. Chair of the ethics committee

Correct Answer is A

Explanation

Rationale:
A. The research participant is the only individual who can provide informed consent for participation in a study. This process ensures that the participant fully understands the purpose, procedures, potential risks and benefits, and their rights, including the right to withdraw from the study at any time without penalty. Obtaining informed consent is a cornerstone of ethical research practice and respects the autonomy and decision-making capacity of the participant. The nurse’s role includes educating the participant, clarifying questions, and ensuring understanding, but the ultimate decision lies with the participant.

B. A risk manager evaluates potential risks in healthcare settings and develops strategies to mitigate them. While they may provide consultation regarding safety or liability, they cannot provide consent on behalf of the client. Their role is administrative and preventive, not participatory in research decision-making.

C. The institutional review board (IRB) is responsible for reviewing and approving research protocols to ensure the safety and ethical treatment of participants. The IRB protects participants at the institutional level but does not enroll or consent individual participants.

D. The chair of the ethics committee provides guidance on ethical dilemmas and ensures that research practices adhere to ethical principles. However, like the IRB, they cannot substitute for the participant’s informed consent. Their role is advisory, not participatory in the consent process.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 evaluating performance improvement measures. Which of the following measurements should the nurse review to determine improvement in client outcomes?

Correct Answer is C

Explanation

A nurse is caring for a client who is eligible for a research study. Which of the following should provide informed consent to enroll in the study?

Correct Answer is A

Explanation

A nurse is performing triage at the site of a mass casualty. For which of the following clients should the nurse assign a yellow tag?

A nurse is planning to assess a group of four postoperative clients. Which of the following clients should the nurse assess first?

A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse enters a client's room and notices a small fire in the client's garbage can. After removing the client from the room, which of the following actions should the nurse take next?

A charge nurse is evaluating a newly licensed nurse's understanding of infection control procedures. Which of the following actions demonstrates that the nurse is following the appropriate protocol for a client who has streptococcal pharyngitis?

A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the following statements by a staff nurse indicate understanding of the teaching? (Select all that apply.)

A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP?