Complete the following sentence by using the list of options.

Exhibits

The nurse should first anticipate the need to
dropdown
and then
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale:

• Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.

• Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.

• Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.

• Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.

• Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.

• Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.

• Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.

• Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale:

A. The client's length of facility stay: The duration of a client’s admission does not determine the appropriateness of delegation. Delegation decisions are based on the client’s current condition and the nature of the task, not how long they have been in the facility.

B. The AP's job description: Verifying the AP’s job description ensures the task falls within their authorized scope of practice. It helps confirm that the AP has the appropriate training and legal authority to carry out the delegated activity safely and competently.

C. The AP's years of experience: While experience may influence efficiency, it is not the primary factor in deciding what can be delegated. A newly trained AP may be competent for certain tasks, while years of experience do not guarantee suitability for all delegated care.

D. The client's age: Age alone does not dictate whether a task can be delegated. Delegation decisions depend more on the client's acuity, stability, and the complexity of care required, rather than demographic factors like age.

A. Occupational therapist B. Social worker C. Primary care provider D. Physical therapist

Correct Answer is B

Explanation

Rationale:

A. Occupational therapist: An occupational therapist helps clients regain skills for daily living and can assess driving ability, but they are not typically responsible for arranging transportation or addressing confidence-related psychosocial issues. A referral may follow but is not the first step here.

B. Social worker: A social worker assists clients with coping and resource coordination, including transportation services, community support, and addressing emotional or confidence barriers. This makes them the most appropriate referral when a client is unsure about attending follow-up care.

C. Primary care provider: While the PCP oversees general medical care and referrals, they are not responsible for coordinating transportation. The nurse can directly initiate a more appropriate referral rather than relying on the PCP for this non-medical concern.

D. Physical therapist: A physical therapist focuses on improving physical function, mobility, and strength. They do not handle transportation issues or confidence concerns related to attending appointments, making them less relevant in this context.

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Complete the following sentence by using the list of options. Exhibits The nurse should first anticipate the need to dropdown and then dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?

A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?

The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Complete the following sentence by using the list of options.

Exhibits

The nurse should first anticipate the need to
dropdown
and then
dropdown
.