What post-op nursing intervention can the Registered Nurse (RN) effectively communicate and delegate to the experienced Nursing Aide (N
Assist the patient to the bathroom.
Teach the patient about weight-bearing precautions.
Assess the pain level.
Instruct the patient on how to use the incentive spirometer.
The Correct Answer is A
Choice A rationale
Assisting the patient to the bathroom is within the scope of practice for a Nursing Aide (NA) and does not require advanced training, making it an appropriate task to delegate while ensuring patient needs are met.
Choice B rationale
Teaching weight-bearing precautions involves patient education, which is the responsibility of the Registered Nurse (RN) due to the need for professional judgment and instruction clarity.
Choice C rationale
Pain level assessment requires critical thinking and professional judgment, which are within the RN’s scope of practice. This cannot be delegated to an NA.
Choice D rationale
Instruction on incentive spirometer use requires understanding of therapeutic goals, patient capability, and respiratory assessment, tasks specific to the RN and beyond the scope of an NA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
Correct Answer is C
Explanation
Choice A rationale
Low urine output could be due to dehydration, medication effects, or stress. While it warrants further assessment, it is not typically associated with immediate life-threatening complications in the context of PUD.
Choice B rationale
Vomiting after a meal can occur in PUD due to delayed gastric emptying or irritation. However, it does not immediately indicate a complication requiring urgent follow-up unless accompanied by other symptoms such as severe pain or hematemesis.
Choice C rationale
Blood in the stool may indicate gastrointestinal bleeding, a serious complication of PUD. This finding requires immediate evaluation to determine the source and extent of bleeding, as it can lead to hypovolemic shock if untreated.
Choice D rationale
Abdominal discomfort is common in PUD due to gastric irritation or acid-related issues. While it requires management, it does not typically signal an urgent complication unless associated with other alarming symptoms.
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