The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Performing chest percussion on a client with atelectasis

Auscultate lungs on a client with audible wheezing

Taking vital signs on a male client with severe dyspnea

Suctioning a client with hemoptysis (bloody sputum)

Setting up a meal tray for a client with COPD

Answer and Explanation

The Correct Answer is E

A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.

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Correct Answer is B

Explanation

A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.
B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.
C. The pulmonic valve closure is associated with the S2 heart sound, not S1.
D. The closure of the pulmonic and aortic valves occurs in S2, not S1.
E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.

A. question the patient about shortness of breath B. palpate the chest and back for masses C. inspect the skin and nails for integrity and color D. Ask the patient about color and quantity of sputum E. auscultate for lung sounds anteriorly and posteriorly

Correct Answer is ["A","D"]

Explanation

A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.

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The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is asked to describe what the heart sound S1 represents. What would be the correct response by the nurse?

Correct Answer is B

Explanation

What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

Correct Answer is ["A","D"]

Explanation

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