After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

42 year old who is due to arrive from the emergency room and has experienced a stroke

43 year old female who is post operative surgery and is bleeding from their wound

82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath

21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Answer and Explanation

The Correct Answer is D

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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Correct Answer is C

Explanation

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. D. The nurse elevates a leg cast when the patient reports decreased mobility.

Correct Answer is A

Explanation

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. This is correct because data validation involves verifying information before taking action. The nurse gathers subjective data from the patient (time of last dressing change) and objective data (drainage) before making a clinical decision.

B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. This is incorrect because the nurse has not validated whether the pain medication can be given early or if other interventions should be attempted first.

C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. This is incorrect because the nurse has not validated whether the leg cramps are due to low potassium. Leg cramps can result from multiple causes, including dehydration or circulatory issues. Lab values should be checked first.

D. The nurse elevates a leg cast when the patient reports decreased mobility. This is incorrect because decreased mobility does not necessarily indicate the need for elevation. Data validation should include assessing for swelling, circulation, and pain before making a decision.

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After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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