Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?
A. The task involves making ongoing judgments about client data.
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
B. The task is within the AP’s range of function to perform.
Choice B is wrong because the task is within the AP’s range of function to perform. This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
C. The task can be performed in the same manner for most clients.
Choice C is wrong because the task can be performed in the same manner for most clients. This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
D. The task requires a specific sequence of steps.
Choice D is wrong because the task requires a specific sequence of steps. This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
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Full Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Similar Questions
A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?
A. Can draw a circle.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
B. Has a vocabulary of four words.
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
C. Jumps with both feet.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
D. Weighs 12 kg (26.5 Ib).
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
Full Explanation
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
A nurse is reinforcing teaching with a client who has a new prescription for verapamil.
Which of the following instructions should the nurse include in the teaching?
A. Expect palpitations for 2 days.
Choice A is wrong because palpitations are not an expected side effect of verapamil, but rather a sign of a possible overdose or a serious heart problem that requires medical attention.
B. Change positions slowly.
Verapamil is a calcium channel blocker that can lower blood pressure and cause dizziness or fainting, especially when standing up from a sitting or lying position. Changing positions slowly can help prevent these symptoms.
C. Take the medication on an empty stomach.
Choice C is wrong because verapamil should be taken with food or milk to avoid stomach upset and increase absorption.
D. Increase calorie intake to minimize weight loss.
Choice D is wrong because verapamil does not cause weight loss, but rather weight gain as a possible side effect. Increasing calorie intake is not necessary and may worsen other health conditions such as diabetes or high cholesterol.
Full Explanation
Verapamil is a calcium channel blocker that can lower blood pressure and cause dizziness or fainting, especially when standing up from a sitting or lying position. Changing positions slowly can help prevent these symptoms.
Choice A is wrong because palpitations are not an expected side effect of verapamil, but rather a sign of a possible overdose or a serious heart problem that requires medical attention.
Choice C is wrong because verapamil should be taken with food or milk to avoid stomach upset and increase absorption.
Choice D is wrong because verapamil does not cause weight loss, but rather weight gain as a possible side effect.
Increasing calorie intake is not necessary and may worsen other health conditions such as diabetes or high cholesterol.
A charge nurse at a long-term care facility ensures that the workload is distributed equally among staff when making assignments.
Which of the following ethical principles is the nurse upholding?
A. Veracity.
Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient. This principle is not relevant to the scenario of making assignments.
B. Justice.
Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.
C. Autonomy.
Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions. This principle is not relevant to the scenario of making assignments.
D. Fidelity.
Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient. This principle is not relevant to the scenario of making assignments.
Full Explanation
Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.
Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient.
This principle is not relevant to the scenario of making assignments.
Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions.
This principle is not relevant to the scenario of making assignments.
Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient.
This principle is not relevant to the scenario of making assignments.