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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Clients in restraints require frequent assessment and documentation, typically every 15 to 30 minutes, to ensure safety and monitor for complications.
B.The initial restraint order must be obtained promptly, usually within 1 hour, not 36 hours.
C.Consent must be obtained from the client or their legal guardian, not just a family member.
D.Restraints cannot be prescribed on a PRN (as needed) basis; orders must be specific and time-limited.
Correct Answer is A
Explanation
A. The first step in conflict resolution is to assess and understand the situation fully. This includes gathering facts from all parties involved before taking action or proposing solutions.
B.Meeting with a committee may be a helpful step later in the process, but not before the manager has all relevant information.
C.While encouraging autonomy is valuable, unresolved conflicts often need structured intervention—especially when affecting team dynamics across shifts.
D.Acknowledging the conflict is important, but doing so without first understanding the root causes may lead to ineffective or superficial resolution.
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