Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

Interpersonal

Intrapersonal

Group

Small group

Answer and Explanation

The Correct Answer is A

A. Interpersonal: The nurse is engaging in interpersonal communication during the admission health history and physical assessment. This form of communication occurs between two individuals and involves a direct exchange of information, thoughts, and feelings. The nurse and the patient interact in a one-on-one setting to gather health information and build rapport.

B. Intrapersonal: Intrapersonal communication refers to communication that occurs within an individual, such as self-talk or internal dialogue. This is not the form of communication used during the nurse's interaction with the patient.

C. Group: Group communication involves interactions among multiple individuals, such as a discussion or meeting with several participants. This does not apply to the nurse's one-on-one interview with the patient.

D. Small group: Small group communication typically involves a few people discussing or working together on a task or topic. Although the nurse may participate in small group discussions, the specific interaction during the admission assessment is classified as interpersonal communication.

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Correct Answer is ["A","C","E"]

Explanation

A. Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). APs are trained to assist with activities of daily living, including bathing, under the supervision of nursing staff. The nurse should ensure that the AP is aware of any special considerations related to the client's recent amputation.

B. Review a low-sodium diet for a client who has hypertension: This task should not be delegated to APs, as it requires nursing knowledge and understanding to educate the client effectively. Discussing dietary modifications involves assessing the client's understanding and providing education, which falls under the nursing scope of practice.

C. Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable and the AP has been trained to assist clients with feeding. However, the nurse should assess the client's swallowing ability and any specific precautions related to the stroke before delegating this task.

D. Explain oral hygiene to a client receiving chemotherapy: This task should not be delegated to APs because it involves providing specific education and instructions regarding oral care, which requires nursing judgment and knowledge about the implications of chemotherapy on oral health.

E. Assist a client to ambulate using a gait belt: This task can be delegated to APs. Assisting with ambulation is within the scope of practice for APs, especially when proper techniques and safety measures, such as using a gait belt, are followed. The nurse should ensure that the AP has received appropriate training to assist with ambulation safely.

A. Wear sterile gloves. B. Wear an N95 respirator mask. C. Wear clean gloves. D. Wear protective eyewear.

Correct Answer is C

Explanation

A. Wear sterile gloves: Sterile gloves are not necessary for checking a pulse. Sterile gloves are typically used for procedures that involve direct contact with sterile areas or instruments. Checking a pulse does not require maintaining a sterile field, so clean gloves are sufficient.

B. Wear an N95 respirator mask: An N95 respirator mask is typically required for airborne precautions, such as those used for tuberculosis, but not for MRSA. MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces, so an N95 mask is not needed for this situation.

C. Wear clean gloves: Wearing clean gloves is the appropriate action when interacting with a client who has MRSA. This helps to prevent the transmission of bacteria and protects both the client and the nurse. Clean gloves should be used for any contact with the client or their environment to minimize the risk of spreading infection.

D. Wear protective eyewear: Protective eyewear is generally used when there is a risk of splashes or sprays of bodily fluids. In this scenario, unless there is a specific risk of such exposure during the pulse check, protective eyewear is not necessary. Clean gloves are the primary requirement for basic contact precautions with MRSA.

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Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?