The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

Turn and reposition the patient every 2 hours.

Assess the patient's skin condition.

Apply hydrocolloid dressing to the pressure injury.

Change pressure injury dressings every shift.

Answer and Explanation

The Correct Answer is A

A. This is a routine, non-clinical task that does not require nursing judgment and can be safely delegated to NAP to help prevent pressure injuries.

B. Assessment is a nursing responsibility and cannot be delegated to NAP. Only a licensed nurse can evaluate the skin’s condition.

C. Wound care requires nursing expertise to ensure proper application and monitoring for signs of infection.

D. Dressing changes require clinical assessment and are outside the scope of NAP practice.

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Correct Answer is C

Explanation

A. Collaborative problem. This is incorrect because a collaborative problem involves complications requiring both medical and nursing interventions. The statement is a nursing diagnosis, not a collaborative problem.

B. Nursing diagnosis. This is incorrect because "Impaired Physical Mobility" is an appropriate NANDA-I approved nursing diagnosis.

C. Etiology. This is correct because "tibial fracture" is a medical diagnosis, and nursing diagnoses should not include medical conditions as the etiology. Instead, the etiology should focus on the patient’s response, such as "pain and muscle weakness" related to the fracture.

D. Defining characteristic. This is incorrect because "patient's inability to ambulate" is an appropriate defining characteristic that supports the diagnosis of impaired mobility.

A. Skip a meal break to catch up on charting. B. Offer to complete another nurse's task. C. Plan time for disruptions. D. Complete the easiest tasks first.

Correct Answer is C

Explanation

A. Skipping breaks can lead to burnout.

B. Taking on another nurse’s task may cause delays in primary responsibilities.

C. Planning for interruptions improves efficiency and prioritization.

D. Completing the easiest tasks first may not be the most efficient approach.

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The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is C

Explanation

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Correct Answer is C

Explanation

A nurse takes a health history, measures vital signs and conducts a physical assessment on a new admission. After data analysis, what should the nurse do next?

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Which of the following signs is most indicative of impaired skin integrity?