A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids."

"An AP may count the respirations of a client who is going to have surgery later the same day."

"An AP may take orthostatic blood pressure measurements from a client who reports dizziness."

"An AP may perform a central line dressing change for a client who is ready for discharge."

Answer and Explanation

The Correct Answer is B

A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.

A. Give the adolescent a short story pamphlet about puberty. B. Describe the steps to the adolescent's guardian. C. Show an online video that demonstrates what to expect. D. Use an anatomically correct puppet to demonstrate.

Correct Answer is C

Explanation

A. Give the adolescent a short story pamphlet about puberty. While educational materials about puberty can be helpful, they do not provide specific information about a pelvic examination.
B. Describe the steps to the adolescent's guardian. The explanation should be directed to the adolescent to ensure they understand and feel comfortable. The guardian may be included if the adolescent prefers.
C. Show an online video that demonstrates what to expect. A visual demonstration can help reduce anxiety by familiarizing the adolescent with the procedure in a clear and informative way.
D. Use an anatomically correct puppet to demonstrate. Puppets are more appropriate for explaining procedures to younger children, not adolescents.

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A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for an adolescent client who is preparing for their first pelvic examination. Which of the following techniques should the nurse use to explain the procedure?

Correct Answer is C

Explanation

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