Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
A. Evaluate dietary intake for a client who has anorexia.
Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Measure the vital signs of a client who just returned from the PACU
Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Arrange the lunch tray for a client who has a hip fracture.
Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Assess I&O for a client who is receiving dialysis.
Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
- B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
- C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
- D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Similar Questions
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
A. Irritability
Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
B. Increased urination
Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
C. Vomiting
Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
D. Facial flushing
Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
Full Explanation
Irritability.
The rationale for each choice is as follows:
- A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
- B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
- C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
- D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
A. Perform gastrostomy feedings through a client's established gastrostomy tube
Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Determine if the PRN pain medication administered 30 min ago has helped
Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Provide instructions about client care to a family member over the telephone
Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teach a client how to measure their own blood pressure
Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.
E. None
None
F. None
None
Full Explanation
A. Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
The client weighs 198 lb, which is equivalent to (198 ÷ 2.2 = 90kg.
Therefore, the amount of mannitol for the test dose is 0.2 g/kg x 90 kg = 18 g. The nurse should administer 18 g of mannitol IV bolus over 5 min as a test dose to the client who has severe oliguria.