You are working on a busy unit and need to delegate tasks to the LPN and M

Asking the LPN to administer an intramuscular injection to a patient.

Asking the LPN to assess a post-operative patient’s wound for signs of infection.

Asking the MA to complete a follow-up call with a patient about test results.

Asking the MA to insert a nasogastric tube in a patient who requires nutritional support.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

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Correct Answer is ["B","F"]

Explanation

Choice A reason: Potassium concentration should be 10-20 mEq/100mL, not 1 mEq/10mL, to avoid irritation. Using an IV controller is correct, making this incorrect, as it’s an unsafe dilution compared to the nurse’s best practices for safe parenteral potassium administration.

Choice B reason: Checking IV access for blood return post-infusion ensures the potassium was delivered correctly, preventing extravasation. This aligns with IV therapy safety, making it a correct best practice the nurse should follow when administering parenteral potassium to the client.

Choice C reason: Pushing potassium as a bolus is dangerous, risking cardiac arrhythmias; it must be infused slowly. IV controller use is correct, making this incorrect, as it’s unsafe compared to the nurse’s best practices for administering potassium to a hypokalemic client.

Choice D reason: Hand veins are unsuitable for potassium, which is irritating and requires larger veins. Checking blood return is correct, making this incorrect, as it risks complications compared to the nurse’s best practices for safe potassium administration in the client.

Choice E reason: Keeping the client NPO is unnecessary for potassium administration, which addresses hypokalemia, not digestion. IV controller use is correct, making this incorrect, as it’s irrelevant to the nurse’s best practices for delivering parenteral potassium safely to the client.

Choice F reason: Using an IV controller ensures a safe, steady infusion rate for potassium, preventing cardiac complications. This aligns with medication safety protocols, making it a correct best practice the nurse should employ when administering parenteral potassium to the hypokalemic client.

A. Assessing for furrows on the tongue to determine dryness of oral mucous membranes. B. Comparing blood pressure measurements in the lying, sitting, and standing positions. C. Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L). D. Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically.

Correct Answer is B

Explanation

Choice A reason: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.

Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.

Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.

Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.

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You are working on a busy unit and need to delegate tasks to the LPN and M

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","F"]

Explanation

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation?

Correct Answer is B

Explanation

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

You are working on a busy unit and need to delegate tasks to the LPN and M

A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

The critical care nurse cares for a client diagnosed with septic shock. Which observation MOST concerns the nurse?

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?