A nurse receives care assignments for a group of clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? (Select all that apply.)

Applying a vacuum-assisted wound closure device on a client's pressure ulcer

Developing a plan of care for a newly admitted client

Preparing a teaching plan for a client who has a new prescription for insulin

Obtaining a client's post-void residual using a bladder scanner

Initiating the administration of a blood transfusion for a client

Answer and Explanation

Correct Answer : A,B,C,E

A.   Applying a vacuum-assisted wound closure device on a client's pressure ulcer: This task requires clinical judgment and advanced training, which are appropriate for an RN.
B.   Developing a plan of care for a newly admitted client: Creating care plans requires comprehensive assessment and clinical decision-making, which are within the RN's scope.
C.   Preparing a teaching plan for a client who has a new prescription for insulin: Teaching requires advanced knowledge to assess learning needs and provide education.
D.   Obtaining a client's post-void residual using a bladder scanner: This task is within the scope of practice for assistive personnel (AP) if trained.
E.   Initiating the administration of a blood transfusion for a client: Blood transfusion initiation requires close monitoring and assessment for adverse reactions, which falls under the RN's scope.

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Correct Answer is C

Explanation

A. Applying the restraint over the client's gown: Restraints should be applied over clothing or a gown to prevent skin irritation and ensure comfort.
B. Using a quick-release knot to secure the restraint: A quick-release knot is the recommended method for securing restraints to ensure they can be removed quickly in an emergency.
C. Placing the restraint across the client's chest: Belt restraints should be placed around the waist, not the chest, as chest placement can impair breathing.
D. Tying the restraint to the bed frame: Restraints should be tied to the bed frame (not the side rails) to prevent injury during bed movement.

A. Client 1 B. Client 2 C. Client 3 D. Client 4

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Client	Tag colour	Rationale
Client 1	Red	The significant blood loss and tourniquet application indicate immediate life-threatening injuries that are survivable with prompt intervention. The heart rate of 54/min is concerning for hypovolemic shock.
Client 2	Black	Fixed and dilated pupils, no pulse, and no spontaneous respirations indicate the client is deceased or has non-survivable injuries.
Client 3	Red	Disorientation, multiple lacerations with significant bleeding, and elevated heart and respiratory rates indicate hemodynamic instability requiring immediate intervention.
Client 4	Yellow	The client is stable, with a suspected arm fracture and minor abrasions. Treatment can be delayed without significant risk of deterioration.

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A nurse receives care assignments for a group of clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is C

Explanation

The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red. yellow, or black tag. A tag color may be assigned to more than one client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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