Question

A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Answer 1

Correct Answers:

Collecting a urine specimen

Rationale :

🧪Collecting a urine specimen is a non-invasive, routine task that can be safely performed by assistive personnel (AP) without the need for clinical judgment.

🧠Tasks like measuring pain levels involve subjective assessment and require a nurse's critical thinking skills, making them inappropriate for delegation.

🩺Monitoring blood glucose levels may involve interpreting results and taking action, which requires nursing judgment depending on the client's condition.

💨Adjusting oxygen flow rates involves technical and safety considerations that are beyond the AP’s scope of practice.

📌Core Message

Delegate only non-invasive, routine, and non-judgment-based tasks to assistive personnel.

Answer 2

Correct Answers:

Sit with a client who has anorexia nervosa during meals.

Rationale :

🪑Sitting with a client during meals is a supportive, non-clinical task that can be safely delegated to AP to encourage nutritional intake.

🧾Witnessing informed consent requires verification of the client’s understanding and legal capacity, which is a licensed nurse's responsibility.

📈Obtaining vitals after a seizure involves monitoring for postictal complications, needing a licensed nurse's assessment skills.

📝Completing incident reports involves documentation for legal and quality assurance purposes, which cannot be delegated to unlicensed staff.

📌Core Message

Delegate supportive behavioral tasks, not those involving legal, assessment, or clinical responsibility.

Answer 3

Correct Answers:

A client who has difficulty swallowing

Rationale :

👅Clients with dysphagia are at risk for aspiration, requiring evaluation by a speech-language pathologist (SLP) for swallowing safety.

🥄Special eating utensils are usually the domain of an occupational therapist, not the SLP.

💪Clients with muscle weakness need broader physical rehabilitation, not necessarily SLP evaluation unless speech or swallowing is impaired.

💨Needing oxygen with ambulation relates to respiratory therapy, not speech pathology.

📌Core Message

Refer to speech-language pathologists for swallowing disorders like dysphagia.

Answer 4

Correct Answers:

Social worker

Rationale :

🏠Social workers provide counseling and psychosocial support and are the appropriate professionals to coordinate family therapy referrals.

🎨Recreational therapists focus on promoting health and well-being through leisure activities, not counseling services.

🧑‍🔬Paramedical technologists are involved in diagnostics, not mental health or therapy coordination.

🛠️Occupational therapists assist with daily living skills, not therapeutic counseling or family dynamics.

📌Core Message

Refer to social workers for psychosocial counseling and family therapy coordination.

Answer 5

Correct Answers:

Hepatosplenomegaly

Rationale :

💁‍♂️Right ventricular heart failure leads to systemic venous congestion, which often causes enlargement of the liver and spleen (hepatosplenomegaly).

📈Pulmonary artery pressure is typically elevated in left-sided or pulmonary heart failure, not isolated right ventricular failure.

👉Crepitus is a sign of subcutaneous emphysema or air leakage, unrelated to heart failure.

🧠Confusion is more often associated with cerebral hypoxia, usually seen in left-sided failure or advanced disease.

📌Core Message

Right-sided heart failure causes systemic congestion signs like hepatosplenomegaly.

Answer 6

Correct Answers:

Pertussis

Rationale :

😷Pertussis (whooping cough) is transmitted via respiratory droplets, requiring droplet precautions to prevent spread.

🦠Varicella-zoster requires airborne and contact precautions, not droplet alone.

🧻Rotavirus is spread through the fecal-oral route, requiring contact precautions, especially with diapered children.

🧫VRE is a multidrug-resistant organism needing contact precautions, not droplet.

📌Core Message

Use droplet precautions for illnesses like pertussis that spread via respiratory secretions.

Answer 7

Correct Answers:

Realign the extremity in traction.

Rationale :

🦴Muscle spasms in skeletal traction often result from misalignment or improper tension on the traction setup.

💁‍♂️Realigning the extremity helps maintain effective traction and reduce painful muscle strain.

🚫Removing weights would disrupt the therapeutic force and is not within nursing scope without provider orders.

📉Increasing traction or resting weights on the floor compromises therapeutic effectiveness and can worsen symptoms.

📌Core Message

Proper alignment in skeletal traction relieves spasms and maintains therapeutic integrity.

Answer 8

Correct Answers:

Hepatitis C

Rationale :

🧪Atorvastatin is contraindicated in clients with active liver disease, such as hepatitis C, due to its hepatotoxic potential.

🧫Conditions like Crohn’s disease, PUD, and bronchitis do not directly impair liver metabolism of the drug.

🛑Use of statins in hepatic conditions can lead to serious liver enzyme elevations and increased risk of liver damage.

📉Hepatic impairment reduces the liver’s ability to process lipid-lowering medications, increasing the risk of toxicity.

📌Core Message

Atorvastatin is contraindicated in liver disease due to hepatotoxic risks.

Answer 9

Correct Answers:

Improve joint functioning.

Rationale :

🦴Glucosamine and chondroitin are dietary supplements commonly used to support joint health, particularly in individuals with osteoarthritis.

🔬They are believed to assist in cartilage repair and maintenance, thereby reducing joint pain and stiffness.

💊While not a cure, they are often part of long-term symptom management for degenerative joint conditions.

🧠There is no evidence to support their use in treating depression, prostate issues, or enhancing immune function.

📌Core Message

Glucosamine and chondroitin help with joint function and may ease arthritis symptoms.

Answer 10

Correct Answers:

Negative Chvostek's sign

Rationale :

🧪A negative Chvostek’s sign indicates the absence of neuromuscular irritability, which is a sign of corrected hypocalcemia.

💉IV calcium administration should reduce symptoms such as tetany, twitching, and positive Chvostek’s or Trousseau’s signs.

📉A calcium level of 8.6 mg/dL is still slightly below the normal range, so it is not considered a complete therapeutic response.

💩Increased bowel motility is associated with hypocalcemia, not its resolution.

📌Core Message

Negative Chvostek’s sign indicates improvement in neuromuscular stability after treating hypocalcemia.

1 :
A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 :
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 :
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

4 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

5 :
A nurse is reviewing the history and physical of a client who has right ventricular. heart failure. Which of the following is an expected finding?

6 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

7 :
A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

8 :
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

9 :
A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

10 :
A nurse is caring for a client who has hypocalcemia and is receiving calcium via IV bolus. Which of the following findings should the nurse identify as a therapeutic response to the medication?

1 : A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 : A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 : A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

4 : A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

5 : A nurse is reviewing the history and physical of a client who has right ventricular. heart failure. Which of the following is an expected finding?

6 : A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

7 : A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

8 : A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

9 : A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

10 : A nurse is caring for a client who has hypocalcemia and is receiving calcium via IV bolus. Which of the following findings should the nurse identify as a therapeutic response to the medication?

1 :
A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 :
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 :
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

4 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

5 :
A nurse is reviewing the history and physical of a client who has right ventricular. heart failure. Which of the following is an expected finding?

6 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

7 :
A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

8 :
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

9 :
A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

10 :
A nurse is caring for a client who has hypocalcemia and is receiving calcium via IV bolus. Which of the following findings should the nurse identify as a therapeutic response to the medication?