The following 4 questions pertain to this case study:

Exhibits

Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?

Monitor for shortness of breath or fatigue after ambulation.

Determine whether the patient is ready to increase activity.

Obtain the patient’s blood pressure and pulse rate after ambulation.

Instruct the patient on how to use an incentive spirometer.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.

Choice B reason:

Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.

Choice C reason:

Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.

Choice D reason:

Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is False

Explanation

Choice A: True

The statement that all patient teaching occurs in a formalized teaching session is not accurate. While formalized teaching sessions are an important aspect of patient education, they are not the only method used. Formal sessions are structured and planned, often involving detailed explanations, demonstrations, and the use of educational materials. These sessions are beneficial for covering complex topics and ensuring that patients and caregivers have a thorough understanding of their health conditions and treatment plans.

Choice B: False

Patient teaching can occur in various settings and formats, not just in formalized teaching sessions. Informal teaching moments are equally important and often occur during routine interactions between healthcare providers and patients. These moments can include brief explanations, answering questions, and providing reassurance during procedures or daily care activities. Informal teaching is flexible and can be tailored to the patient’s immediate needs and readiness to learn, making it a crucial component of effective patient education.

A. Hypotonic B. Oncotic pressure C. Isotonic D. Hypertonic

Correct Answer is C

Explanation

Choice A: Hypotonic

A hypotonic solution has a lower concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypotonic solution, water enters the cells, causing them to swell and potentially burst. This is because the osmotic pressure drives water into the cells to balance the solute concentration. Hypotonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.

Choice B: Oncotic Pressure

Oncotic pressure, also known as colloid osmotic pressure, is the form of osmotic pressure exerted by proteins, primarily albumin, in the blood plasma. It plays a crucial role in maintaining fluid balance between the blood vessels and the surrounding tissues by pulling water into the circulatory system. Oncotic pressure is not related to the concept of equal osmolality between extracellular and intracellular fluids.

Choice C: Isotonic

An isotonic solution has the same concentration of solutes as the fluid inside the cells. When extracellular fluid is isotonic to intracellular fluid, there is no net movement of water into or out of the cells, maintaining cell stability. This balance is crucial for normal cellular function and is the term used to describe equal osmolality between extracellular and intracellular fluids.

Choice D: Hypertonic

A hypertonic solution has a higher concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypertonic solution, water leaves the cells, causing them to shrink or crenate. This occurs because the osmotic pressure drives water out of the cells to balance the solute concentration. Hypertonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.

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The following 4 questions pertain to this case study: Exhibits Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

All patient teaching occurs in a formalized teaching session.

Correct Answer is False

Explanation

Which term would the nurse use when extracellular fluid and intracellular fluid have the same osmolality?

Correct Answer is C

Explanation

Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?

The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.

The following 4 questions pertain to this case study: Exhibits The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Neutropenia increases the patient’s risk for life-threatening infection and sepsis.

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)

Which infection control actions would the nurse include in the use of standard precautions?

The OR nurse gives an SBAR to the PACU nurse. This verbal report should include which four statements?

The following 4 questions pertain to this case study:

Exhibits

Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?