The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task?
The nurse should review the patient's vital signs as soon as they are done.
The nurse assistant should not be responsible for obtaining vital signs.
The nurse is not responsible if the nurse assistant fails to obtain the vital signs.
The nurse assistant should determine if the patient's vital signs are abnormal.
The Correct Answer is A
A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Calculation:
To determine the volume to administer, use the formula:
Volume = (Dose ordered/ Dose available)× mL per dose
Given:
- Ordered dose = 37.5 mg
- Available concentration = 12.5 mg/5 mL
Volume = (37.5/12.5)× 5mL
= 3× 5mL
= 15mL
Thus, the nurse will administer 15 mL.
Correct Answer is D
Explanation
A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.
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