Which action should the practical nurse (PN) implement when performing a focused assessment?
Wear clean gloves during auscultation of a client's heart sounds, lung sounds, and bowel sounds.
Dispose of gastric residual volume obtained when aspirating a client's nasogastric tube.
Weigh a mother holding her infant then subtract the mother's weight to obtain the infant's weight.
Place the blood pressure cuff on the thigh of a client with burns to the upper extremities.
The Correct Answer is B
A. Wear clean gloves during auscultation of a client's heart sounds, lung sounds, and bowel sounds. Gloves not required for auscultation unless contact with body fluids is anticipated.
B. Dispose of gastric residual volume obtained when aspirating a client's nasogastric tube: Standard practice unless facility policy specifies reinsertion; prevents aspiration risk.
C. Weigh mother holding infant then subtract the mother's weight to obtain the infant's weight: Not part of a focused assessment but a measurement technique.
D. Place BP cuff on thigh of a client with burns to the upper extremities: Adaptation for burn injuries but not related to general focused assessment steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in progress:
Pain assessment and medication administration require licensed personnel. The PN should finish the current task and promptly address the client in pain.
B. Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic:
UAPs cannot administer tube feedings unless trained and delegated appropriately, and in most settings, PEG bolus feeding is the PN’s responsibility.
C. Tell the UAP that the client's pain will subside when the client is not disturbed:
Ignoring or delaying pain relief is inappropriate and unethical.
D. Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client:
Measuring gastric residual requires clinical judgment and is a PN responsibility, not a UAP task.
Correct Answer is C
Explanation
A. The Patient's Bill of Rights: Important for patient care standards, but does not specifically define delegation limits.
B. The healthcare agency policy regarding working 12-hour shifts: Addresses scheduling, not the scope of tasks.
C. The state's Nurse Practice Act regarding delegation to unlicensed personnel: This legally defines what tasks can be delegated to UAPs.
D. The client's informed consent allowing unlicensed personnel to provide care: Consent does not override legal delegation limits.
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