Question

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

Answer 1

Correct Answers:

Anchor an inserted urinary catheter in place with tape.

Rationale :

🔷UAPs can be delegated non-sterile, routine tasks that do not require nursing judgment, such as securing devices after insertion.

🔷Monitoring IV infusion rates, preparing a sterile field, and wound care all require assessment skills or sterile technique, which are outside a UAP’s scope.

🔷Anchoring a catheter is considered a safety and comfort task to prevent accidental dislodgement.

🔷Delegation must always consider stability of the client, predictability of the task, and legal practice boundaries.

🔷The RN retains accountability for overall care but assigns supportive measures to the UAP.

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Answer 2

Correct Answers:

Confirm that the desired effect of the medication has been achieved.

Rationale :

🟠Trazodone is primarily prescribed for insomnia and mood symptoms, not for improving cognition.

🟠The caregiver’s report of improved mood and sleep indicates the medication is effective for its intended purpose.

🟠Alzheimer’s disease requires other medications, such as cholinesterase inhibitors, to slow cognitive decline.

🟠Nurses must reinforce realistic expectations about medication outcomes to reduce caregiver frustration.

🟠Providing accurate education ensures safe and appropriate continuation of treatment.

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Answer 3

Correct Answers:

"Would you like me to sit with you for a while?"

Rationale :

🔴When anxiety is overwhelming, clients may not be able to process complex or abstract questions.

🔴Offering presence provides immediate support and safety, reducing isolation.

🔴Simple, short interactions help the client feel grounded and less threatened.

🔴Once anxiety is reduced, the nurse can then explore causes, coping patterns, and goals.

🔴This approach reflects the principle of Maslow’s hierarchy, prioritizing safety and emotional stabilization.

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Answer 4

Correct Answers:

Encouraging liberal fluid intake.

Rationale :

🟢Fever causes insensible fluid loss, increasing risk for dehydration.

🟢Antipyretics lower temperature but do not replace fluids lost during fever.

🟢Adequate hydration supports thermoregulation, circulation, and kidney function.

🟢External cooling or warm blankets may either counteract or worsen shivering, making fluids the safest supportive measure.

🟢Nursing interventions must complement medication effects to restore homeostasis.

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Answer 5

Correct Answers:

Send a stool sample to the lab for a guaiac test.

Rationale :

♦️Clients on thrombolytic therapy are at high risk for internal bleeding, including GI hemorrhage.

♦️Occult (hidden) blood in stool may be the first indicator of bleeding complications.

♦️A guaiac test allows for early detection and prompt intervention.

♦️Clay-colored stool would suggest liver issues, not thrombolytic effects.

♦️Monitoring for bleeding is the priority safety concern after thrombolytics.

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Answer 6

Correct Answers:

A family member expresses concern about their relative -picking" at the nasal gastric tube (NG) tube.

Rationale :

🔷Mitten restraints are used to prevent clients from removing medical devices such as NG tubes, IVs, or catheters.

🔷This type of restraint limits hand use but is less restrictive than wrist restraints.

🔷It is considered when less restrictive interventions (distraction, covering the tube) are unsuccessful.

🔷The decision must be discussed with the provider and documented thoroughly.

🔷Client safety and device integrity are the guiding principles.

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Answer 7

Correct Answers:

Measure the client's body weight each morning.

Rationale :

⏺️Weight measurement is a routine, predictable task appropriate for delegation to the PN.

⏺️Evaluating staff performance, client teaching, and setting parameters require RN judgment and authority.

⏺️Daily weight is essential in chronic conditions like CHF or renal disease but does not require higher-level assessment.

⏺️Delegation ensures efficient use of the nursing team’s skills while maintaining safety.

⏺️The RN maintains responsibility for reviewing and interpreting results.

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Answer 8

Correct Answers:

Raise the head of the bed only to 30 degrees.

Rationale :

🔴Limiting the head of bed elevation reduces shearing forces, which worsen pressure injuries.

🔴Eschar covering a wound indicates full-thickness tissue damage that requires pressure relief as a priority.

🔴Foam mattresses, ROM exercises, and vitamins support healing but do not address the mechanical cause of breakdown.

🔴Positioning is a key intervention to prevent further injury and promote circulation to the area.

🔴Maintaining HOB ≤30 degrees balances respiratory needs with skin protection.

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Answer 9

Correct Answers:

Initiate a continuous infusion of IV fluids per prescription.

Rationale :

🟢Infants with pyloric stenosis experience severe vomiting, leading to dehydration and metabolic alkalosis.

🟢Rehydration and electrolyte correction are the top pre-op priorities to stabilize the infant.

🟢IV fluids ensure adequate perfusion and safety during anesthesia.

🟢Other interventions (education, marking mass, monitoring feedings) are important but secondary to stabilization.

🟢 Surgery is delayed until the infant is medically stable.

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Answer 10

Correct Answers:

Maintains blood pressure within normal limits.

Rationale :

💎Chronic pyelonephritis can progress to renal scarring and chronic kidney disease, which often causes hypertension.

💎Controlling blood pressure is essential to preserve kidney function and prevent further damage.

💎Daily temperature is not a long-term goal; independence in ADLs is important but not specific to pyelonephritis.

💎Fluid restriction to 1 L/day is not recommended unless renal failure occurs.

💎Blood pressure control reflects successful long-term management and reduces risk of end-stage renal disease.

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QLexNursing

1 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

2 :
A client with Alzheimer's disease (AD) is receiving trazodone. a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no in cognitive How should the nurse respond to this information?

3 :
The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

4 :
After administering an antipyretic medication, which intervention should the nurse implement?

5 :
A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement. Which action should the nurse implement?

6 :
Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

7 :
The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safety to the practical nurse (PN)?

8 :
The nurse is caring for a client who is immobile and developed a stage IV pressure injury swum. The eschar in the wound bed. Which intervention is most important for the nurse to implement?

9 :
A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

10 :
Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

QLexNursing

1 : The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

2 : A client with Alzheimer's disease (AD) is receiving trazodone. a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no in cognitive How should the nurse respond to this information?

3 : The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

4 : After administering an antipyretic medication, which intervention should the nurse implement?

5 : A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement. Which action should the nurse implement?

6 : Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

7 : The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safety to the practical nurse (PN)?

8 : The nurse is caring for a client who is immobile and developed a stage IV pressure injury swum. The eschar in the wound bed. Which intervention is most important for the nurse to implement?

9 : A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

10 : Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

1 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

2 :
A client with Alzheimer's disease (AD) is receiving trazodone. a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no in cognitive How should the nurse respond to this information?

3 :
The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

4 :
After administering an antipyretic medication, which intervention should the nurse implement?

5 :
A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement. Which action should the nurse implement?

6 :
Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

7 :
The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safety to the practical nurse (PN)?

8 :
The nurse is caring for a client who is immobile and developed a stage IV pressure injury swum. The eschar in the wound bed. Which intervention is most important for the nurse to implement?

9 :
A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

10 :
Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?