The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?

Administering tube feedings to a quadriplegic client.

Assisting with bowel training by placing the client on the bedside commode.

Observing the client demonstrating a self-catheterization technique.

Teaching Crede's maneuver to a client needing to void.

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

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Correct Answer is C

Explanation

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

A. "Let's evaluate what went wrong and develop policies for future incidents." B. "This session is only for nursing and medical staff, not for ancillary personnel." C. "Let's pass around the disaster written policy for everyone to review." D. "You are free to express your feelings, whatever is said here stays here."

Correct Answer is D

Explanation

Choice A reason: While evaluating what went wrong and developing policies for future incidents is important, this statement is more suited for an after-action review or a quality improvement session. A critical incident stress debriefing focuses on the emotional and psychological support for staff rather than policy evaluation.

Choice B reason: Excluding ancillary personnel from the debriefing session is inappropriate. All staff involved in the incident, including ancillary personnel, should be included in the debriefing to address their emotional and psychological needs. This statement does not support the inclusive nature of debriefing sessions.

Choice C reason: Passing around the disaster written policy for review is not appropriate for a stress debriefing session. The purpose of a debriefing is to provide a safe space for staff to express their emotions and experiences rather than reviewing policies.

Choice D reason: This statement is appropriate for a critical incident stress debriefing as it encourages staff to express their feelings openly and assures them of confidentiality. Creating a safe and supportive environment is essential for addressing the emotional and psychological impact of the incident on staff.

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The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

Correct Answer is C

Explanation

The nurse manager of the emergency department arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?

Correct Answer is D

Explanation

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