Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse requests that an assistive personnel (AP) change all the linens and give bed baths to four clients on the unit. The previous day, the AP was not able to complete these same tasks. Which of the following actions should the nurse take in addressing this situation?
A. Offer to help the AP complete the tasks.
Offering to help the AP complete the tasks may seem like a good solution in the short term. However, this approach does not address the underlying issue, which is that the AP was not able to complete these tasks the previous day. The nurse’s role is to delegate tasks appropriately and ensure that all tasks are completed in a timely manner. If the nurse takes over the AP’s tasks, it could lead to an imbalance in the workload and could potentially overburden the nurse. Therefore, while this choice may seem helpful, it is not the most effective solution to the problem.
B. Assign a more qualified staff member to the tasks.
Assigning a more qualified staff member to the tasks could be a potential solution if the AP’s inability to complete the tasks was due to a lack of skills or knowledge. However, without more information, it’s not clear that this is the case. Furthermore, this approach could lead to resentment among staff if it appears that tasks are not being distributed fairly. Therefore, while this choice could be a potential solution, it is not the most effective solution given the information provided.
C. Plan a more reasonable job assignment.
Planning a more reasonable job assignment is the most effective solution to this problem. If the AP was not able to complete the tasks the previous day, it suggests that the workload was too heavy or the tasks were too complex. By reassessing the job assignment and making it more manageable, the nurse can ensure that all tasks are completed in a timely manner. This approach respects the abilities and limitations of the AP, promotes a fair distribution of tasks, and ensures the best care for the clients.
D. Set a time frame for the AP to complete the tasks.
Setting a time frame for the AP to complete the tasks could be a potential solution if the issue was that the tasks were not completed in a timely manner. However, if the AP was not able to complete the tasks at all, simply setting a time frame may not resolve the issue. This approach could also add unnecessary pressure on the AP, which could lead to rushed or substandard work. Therefore, while this choice could be a potential solution, it is not the most effective solution given the information provided.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Medical Surgical Leadership Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice C.
Choice A rationale: Offering to help the AP complete the tasks may seem like a good solution in the short term. However, this approach does not address the underlying issue, which is that the AP was not able to complete these tasks the previous day. The nurse’s role is to delegate tasks appropriately and ensure that all tasks are completed in a timely manner. If the nurse takes over the AP’s tasks, it could lead to an imbalance in the workload and could potentially overburden the nurse. Therefore, while this choice may seem helpful, it is not the most effective solution to the problem.
Choice B rationale: Assigning a more qualified staff member to the tasks could be a potential solution if the AP’s inability to complete the tasks was due to a lack of skills or knowledge. However, without more information, it’s not clear that this is the case. Furthermore, this approach could lead to resentment among staff if it appears that tasks are not being distributed fairly. Therefore, while this choice could be a potential solution, it is not the most effective solution given the information provided.
Choice C rationale: Planning a more reasonable job assignment is the most effective solution to this problem. If the AP was not able to complete the tasks the previous day, it suggests that the workload was too heavy or the tasks were too complex. By reassessing the job assignment and making it more manageable, the nurse can ensure that all tasks are completed in a timely manner. This approach respects the abilities and limitations of the AP, promotes a fair distribution of tasks, and ensures the best care for the clients.
Choice D rationale: Setting a time frame for the AP to complete the tasks could be a potential solution if the issue was that the tasks were not completed in a timely manner. However, if the AP was not able to complete the tasks at all, simply setting a time frame may not resolve the issue. This approach could also add unnecessary pressure on the AP, which could lead to rushed or substandard work. Therefore, while this choice could be a potential solution, it is not the most effective solution given the information provided.
Similar Questions
A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?
A. A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg.
A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
B. A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10.
A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
C. A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr
A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
Full Explanation
The correct answer is Choice C.
Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?
A. Collecting intake and output.
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Collecting intake and output [a] is a task that can be delegated to an AP.
B. Evaluating pain relief after administering pain medication.
involves assessing the effectiveness of a medical intervention, which is typically the responsibility of a licensed nurse.
C. Providing a central line dressing change.
is a complex task that requires specialized knowledge and skills.
D. Selecting a menu for a low-sodium diet.
involves dietary planning, which is typically the responsibility of a licensed nurse or a registered dietitian.
Full Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Collecting intake and output [a] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP.
Evaluating pain relief after administering pain medication [b] involves assessing the effectiveness of a medical intervention, which is typically the responsibility of a licensed nurse.
Providing a central line dressing change [c] is a complex task that requires specialized knowledge and skills.
Selecting a menu for a low-sodium diet [d] involves dietary planning, which is typically the responsibility of a licensed nurse or a registered dietitian.
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following actions jeopardize client confidentiality? (Select all that apply.)
A. Removing client information from fax machines immediately.
B. Discussing clients at the table in the cafeteria.
C. Disposing of written report sheets into the facility trash receptacle.
D. Giving verbal reports at the change of shift in a designated conference room.
Full Explanation
Discussing clients at the table in the cafeteria [b], disposing of written report sheets into the facility trash receptacle [c], and sharing a personal password with a coworker [e] are all actions that jeopardize client confidentiality. Client information should be kept private and secure at all times. Discussing clients in public places or disposing of client information in an unsecured manner can result in unauthorized access to confidential information. Sharing personal passwords can also compromise the security of client information.
The other options do not jeopardize client confidentiality. Removing client information from fax machines immediately [a] helps to prevent unauthorized access to confidential information. Giving verbal reports at change of shift in a designated conference room [d] is a standard practice that allows for the secure transfer of client information between healthcare providers.