Which four of the patient orders can be delegated to the nursing aide? Select all four that apply.
Insert indwelling urinary catheter.
Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr.
Empty urinary catheter and measure the output.
Collect a stool sample for occult blood testing.
Daily weights.
Notify the MD of any signs of bleeding.
Vital signs every 4 hours.
Correct Answer : C,D,E,G
Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Low T4 levels do not indicate hyperthyroidism. In fact, low levels of T4 are typically associated with hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones.
Choice B reason: High T4 levels are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland is overactive and produces excessive amounts of thyroid hormone (T4), leading to elevated T4 levels in the blood.
Choice C reason: Low TSH levels are also indicative of hyperthyroidism. The pituitary gland secretes TSH to regulate thyroid hormone production. When thyroid hormone levels are high, as in hyperthyroidism, the pituitary gland reduces TSH secretion, resulting in low TSH levels.
Choice D reason: High TSH levels are not associated with hyperthyroidism. Elevated TSH levels are more commonly seen in hypothyroidism, where the thyroid gland is underactive, and the pituitary gland compensates by increasing TSH production to stimulate the thyroid gland.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Hypotension is not typically associated with hyperthyroidism. In fact, hyperthyroidism usually leads to an increase in metabolic rate, which can cause an increase in blood pressure rather than a decrease. Therefore, hypotension is not a consistent finding in patients with hyperthyroidism.
Choice B reason: Diaphoresis, or excessive sweating, is a common symptom of hyperthyroidism. The increased metabolic rate associated with hyperthyroidism causes the body to generate more heat, leading to excessive sweating as the body attempts to cool down. This symptom is frequently observed in patients with this condition.
Choice C reason: Heat intolerance is a hallmark symptom of hyperthyroidism. Due to the increased metabolic activity, patients with hyperthyroidism often feel excessively warm and have difficulty tolerating heat. They may seek cooler environments and prefer lighter clothing, even in colder weather, to manage their discomfort.
Choice D reason: Tachycardia, or an abnormally rapid heart rate, is a common finding in hyperthyroidism. The excess thyroid hormones stimulate the heart, leading to an increased heart rate and palpitations. This symptom is a significant indicator of hyperthyroidism and is often one of the first signs noticed by patients and healthcare providers.
Choice E reason: Insomnia is frequently seen in patients with hyperthyroidism. The increased metabolic rate and heightened nervous system activity can lead to difficulty sleeping and restlessness. Patients may report trouble falling asleep, staying asleep, or feeling rested after sleep, contributing to overall fatigue and irritability.
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