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.

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Correct Answer is C

Explanation

A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.

A. Dose B. Time C. Medication D. Route

Correct Answer is B

Explanation

A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.

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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 caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

Correct Answer is C

Explanation

A nurse is reviewing a medication prescription that reads, "Morphine 5 mg IV bolus for pain". Which of the following components should the nurse clarify with the provider?

Correct Answer is B

Explanation

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