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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: Lithium can cause nephrogenic diabetes insipidus, not SIADH, which involves excess ADH. Lung cancer is a known SIADH trigger, making this incorrect, as it’s unrelated to the syndrome compared to the high-risk client with cancer and vincristine therapy.

Choice B reason: Losartan treats hypertension in renal artery stenosis but doesn’t cause SIADH, which is linked to cancers. Lung cancer with vincristine is riskier, making this incorrect, as it’s not associated with the syndrome in the nurse’s risk assessment of clients.

Choice C reason: Lung cancer, especially small cell, and vincristine are strongly associated with SIADH due to ectopic ADH production. This aligns with oncology risk factors, making it the correct client most at risk for SIADH in the nurse’s outpatient clinic care.

Choice D reason: Hyperthyroidism and methimazole don’t typically cause SIADH, unlike lung cancer’s strong link. Vincristine-treated cancer is the highest risk, making this incorrect, as it’s not a primary cause of SIADH in the nurse’s evaluation of the outpatient clients.

A. Maintain NPO (nothing by mouth) status. B. Encourage coughing and deep breathing. C. Give small, frequent high-calorie feedings. D. Maintain the client in a supine and flat position. E. Give hydromorphone intravenously as prescribed for pain. F. Maintain intravenous fluids at 10 mL/hr to keep the vein open.

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

Explanation

Choice A reason: NPO status rests the pancreas, reducing enzyme secretion in acute pancreatitis. This aligns with treatment protocols, making it a correct intervention the nurse would expect to be prescribed for the client to manage pancreatic inflammation effectively.

Choice B reason: Coughing and deep breathing prevent respiratory complications like atelectasis in pancreatitis patients, who are often immobile. This aligns with standard care, making it a correct intervention the nurse would anticipate in the client’s treatment plan.

Choice C reason: Small, frequent high-calorie feedings are contraindicated in acute pancreatitis, as they stimulate the pancreas. NPO is correct, making this incorrect, as it’s inappropriate for the nurse’s expected interventions in managing acute pancreatitis.

Choice D reason: Supine and flat positioning may increase discomfort and aspiration risk in pancreatitis. Semi-Fowler’s is preferred, making this incorrect, as it’s not an expected intervention compared to the nurse’s focus on optimal positioning for the client.

Choice E reason: Hydromorphone IV provides effective pain relief in acute pancreatitis, reducing patient discomfort. This aligns with pain management protocols, making it a correct intervention the nurse would expect to be prescribed for the client’s care.

Choice F reason: IV fluids at 10 mL/hr are insufficient for pancreatitis, which requires aggressive hydration. Higher rates are standard, making this incorrect, as it’s inadequate compared to the nurse’s expected fluid management in acute pancreatitis treatment.

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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

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Correct Answer is C

Explanation

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that apply)

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

Explanation

A client diagnosed with viral hepatitis is complaining of “no appetite” and “losing my taste for food.” What instruction would the nurse give the client to provide adequate nutrition?

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?