Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?
Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
With one other CNA logroll a client who has had a bicycle accident
Obtain a weight on a newly admitted client with diabetes
Assist a client to the bathroom 1 hour after a lumbar puncture
The Correct Answer is C
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid resuscitation
Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.
B. Transfer to a burn center
While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.
C. Application of sterile dressings
Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.
D. Administer morphine 8 mg IV
Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.
Correct Answer is ["A","C","D"]
Explanation
A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.
B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.
C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.
D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.
E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.
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