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 AP requires intervention by the nurse?

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

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

Evaluates the effectiveness of the client's pain medication

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

Answer and Explanation

The Correct Answer is C

A. Ambulating a client who is 2 days postoperative can be delegated to an AP if the nurse has assessed the client and determined it is safe.
B. Measuring urinary output from an indwelling catheter is within the AP’s scope of practice and does not require intervention.
C. Evaluating the effectiveness of pain medication requires nursing judgment and is not within the AP’s role. This action requires intervention by the nurse.
D. Performing a simple dressing change may be delegated to an AP if the wound is not complex and the nurse has provided proper instruction.

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Correct Answer is C

Explanation

A. This is a sign of fluid overload and worsening heart failure, indicating the initiative may not be successful.
B. An S3 heart sound is associated with heart failure and indicates poor ventricular function.
C. BNP levels rise in response to heart failure and fluid overload. A decrease in BNP indicates improvement in heart function and effective management, suggesting the quality improvement initiative is working.
D. Rapid weight gain is a sign of fluid retention and worsening heart failure, indicating poor outcomes.

A. Admit the injured clients to positive-pressure rooms. B. Remove contaminated clothing. C. Scrub the clients' skin with betadine solution. D. Place shower caps over the clients' hair.

Correct Answer is B

Explanation

A.Positive-pressure rooms are not appropriate for contaminated clients; negative-pressure or decontamination areas are preferred to prevent spread.
B.Removing contaminated clothing is a critical first step to reduce chemical exposure and prevent secondary contamination.
C.Scrubbing skin with betadine is not recommended as it may cause further irritation or harm; gentle washing with water is preferred.
D.Placing shower caps over hair does not remove contamination; thorough decontamination requires removal of clothing and washing.

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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 AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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